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Still University of Health Sciences at the Kirksville location. The sliding fee is based on household size and total income up to 200% of the current Health and Human Services Poverty Guidelines. Applicants list names, date of birth, and total income from IRS 1040 and all individuals. Proof of income documentation is required for tax filed and non-tax filed cases, including IRS 1040, W-2, pay stubs, self-employment records, or letters confirming no income. 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Still University of Health Sciences  \n800 West Jefferson Kirksville, MO 63501  \nSLIDING FEE SCALE  \nREQUIREMENTS  \nA.T Still University of Health Sciences offers a need-based sliding fee scale in our Kirksville location to help make healthcare costs more affordable for qualifying patients. The sliding scale is based on family size and income level up to 200% of the current Health and Human Services Poverty Guidelines.  \nAPPLICATION FORM  \nApplicant Names  \nDate ofBirth  \nTotal Income from 1040 Tax Return and Income for all individuals  \nPROOF OF INCOME FOR THE HOUSEHOLD  \nRequired when an income tax return has been filed  \na) IRS 1040 Income Tax Form  \n• Dependents listed on IRS 1040 ages 18 and over must provide one of the following:  \n• Two letters of unemployment if not working  \n• IRS 1040  \n• Copy of pay stubs for prior month  \n• W-2  \nRequired when an income tax return has not been filed  \nOne (1) of the following acceptable proofs of income  \n• Copy of most current W-2-use Box 1 as Gross Income  \n• Copy of pay stubs for all incomes for 1 month (a minimum of 2 stubs if paid monthly)  \n• Self-employed individuals must provide accounting of income or quarterly tax payments  \n• Social Security will NOT be counted as household income for purposes of determining slide eligibility and category.  \n• Two letters (2) from non-family members confirming that the patient has no income. The letter should include printed name, signature and date.  \n➢ Discounts will be applied ONLY 30 days prior to the completion of the application.  \n➢ The slide information covers the current fiscal year (July to June), and only individuals listed on the application are covered.  \n➢ Slide category is based only on the number of qualified individuals and income verification.  \n➢ Your copay is due at the time of service.  \nPlease contact the A.T. Still University of Health Sciences if you have any questions at 660-626-2050.  \nSERVICES CANNOT BE DISCOUNTED UNTIL THE APPLICATION AND CONFIRMATION  \nOF INCOME ARE COMPLETED.  \nA.T Still University of Health Sciences Due Back Approx  \nApplication for Sliding Fee Scale  / /   \nDiscount  \nA.T Still University of Health Science may be able to offer services at a discounted price based on the number of members in your household and your combined income. If you wish to determine the amount of discount available to you, the following information is required. Information reported should be as accurate and complete as possible and will be kept completely confidential.  \n\n| *HOH | Entered in\u003Cbr>UDS | Last Name | First Name | Marital Status | DOB | Age | Relationship to applicant |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n|  |  |  |  |  |  |  | Self |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n\nYour discount will apply to all our clinics, but not all services are covered by the sliding fee program.  \nPlease inquire before services are provided if you need to be informed of covered services.  \nIf you have insurance, your signature on this form is our release to file your insurance for the full amount of services provided. The clinic is entitled to recover the full amount charged from insurance and will slide off the balance only after all insurance payments or denials have been received.  \nIf proof of income is not received and the slide application is not completed within 30 days of services, the patient must pay the full charge. The application qualifies the individuals listed above for the slide category determined for the entire current fiscal year based on the date the application is completed. Our fiscal year is from July1 through June 30th and a new application must be completed every fiscal year.  \nI have read and understand all of the information. All information recorded is correct, truthful and complete. If thereis a change in the number of applicants or my f","cbCaikr9vuNeex2s","https://ap.wps.com/l/cbCaikr9vuNeex2s","pdf",533720,"English","# Sliding Fee Scale Requirements\n## Application Form Details\n## Proof of Income Documents\n## Eligibility Rules and Payment Terms","[{\"question\":\"What determines eligibility for the sliding fee scale?\",\"answer\":\"Eligibility is based on household size and total income level, up to 200% of the current Health and Human Services Poverty Guidelines.\"},{\"question\":\"What income documents are required if an income tax return was filed?\",\"answer\":\"Applicants must provide IRS 1040 (including dependent requirements) and appropriate documentation for dependents, such as unemployment letters or IRS 1040, pay stubs, or W-2 as specified.\"},{\"question\":\"When will discounts be applied and what services are covered?\",\"answer\":\"Discounts are applied only 30 days prior to the completion of the application. The discount applies to all clinics, but not all services are covered; covered services should be confirmed before treatment.\"}]","SLIDING FEE SCALE - REQUIREMENTS - APPLICATION FORM | PDF",1789791284]