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When PG is at or below 100%, no fee applies; above 100% through defined brackets sets the patient’s percentage of the published charge. The form requests personal, employer, insurance, and detailed income-source information, requires supporting proof, and includes a declaration and signature, with review and validity for one year except self-declaration.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/sliding-fee-scheduleincome-verification-form-protocol-2018/275695/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/sliding-fee-scheduleincome-verification-form-protocol-2018/275695.png","ImageObject",442,249,{"name":88,"@type":89},"wps_ap_test_251126_0180","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-11-01","2026-09-15",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",6,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"How is the sliding fee calculated?","Question",{"text":109,"@type":110},"The sliding fee is based on income and family size compared to Federal Poverty Guidelines, expressed as Percent of Guideline (PG). Fee eligibility and the patient’s percentage of the published charge depend on the PG bracket.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"When is an Income Verification Form required?",{"text":114,"@type":110},"An Income Verification Form must be completed every 12 months, or whenever there is a change in income and/or household size.",{"name":116,"@type":107,"acceptedAnswer":117},"What documents can be used to verify income?",{"text":118,"@type":110},"Acceptable proof includes paystubs, employer letters, tax returns, W-2s/1099s, Social Security award letters, disability or unemployment award letters, and other specified documentation such as child support verification or a self-declaration form for a first visit.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},275695,1790314986,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":79,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":73},8796095027276,"https://avatar.qwps.com/avatar/d3BzX2FwX3Rlc3RfMjUxMTI2XzAxODA=","Sliding Fee Schedule/Income Verification Form  \nPatient Name:    \nPolicy: the sliding fee is based on two factors: your income and family size compared to the Federal Poverty Guidelines known as your Percent of Guideline (“PG”) . If PG is at or below 100% you will not pay a fee. If PG is above 100% and at or below 150% you will pay 25% of the published charge. If PG is above 150% and at or below 200% you will be 50% of the published charge. If PG is above 200% and at or below 250% you will pay 75% of the published charge. If PG is above 250% you are not eligible for the sliding fee.  \nWe appreciate the opportunity to provide you with health services. It is necessary for us to ask personal questions in order to give you a discount on your expenses. This information will be kept on file in our center in strict confidence. You must complete an Income Verification Form every 12 months or if there is a change in your income and/or household size. In order to qualify for the sliding fee scale, you must provide one of the following sources of information:  \n\n| ● Paystubs-previous month’s paystubs | ● Disability award letter |\n| --- | --- |\n| ● Letter from Employer stating monthly income | ● Unemployment award letter |\n| ● Tax Return-most recent | ● Veteran’s Administration award letter |\n| ● W-2’s or 1099’s – most recent | ● Child Support Verification |\n| ● Social Security award letter | ● Letter from party providing room & board |\n| ● Self Declaration Form – only valid for the first visit for a new patient | ● Documentation on ineligibility for Medicaid, other public programs and/or private/third party coverage (i.e. Health Reform) |\n\nName of employer:   Phone:    \nSpouse’s employer:   Phone:    \nDo you receive any income from any of the following sources and if so, how much?  \n\n| Sources | You | Your Spouse | Your Children | Other Person | Total Sources |\n| --- | --- | --- | --- | --- | --- |\n| Social Security |  |  |  |  |  |\n| Public Assistance |  |  |  |  |  |\n| Retirement Pension |  |  |  |  |  |\n| Food Stamps |  |  |  |  |  |\n| Rental Income |  |  |  |  |  |\n| Interest Income |  |  |  |  |  |\n| Child Support/Alimony |  |  |  |  |  |\n| Other (specify) |  |  |  |  |  |\n\nDo you have any type of insurance? ☐ Yes ☐ No  \nInsurance carrier:   Insurance Policy Number   \nI declare the above information is true and have given Community Health Resources, Inc. permission to investigate any information given in this application. I understand that this information will be kept in strict confidence. I also understand that I must complete Income Verification form every 12 months or if there is a change in my household income or size. In addition, I must provide the required proof of income and household documentation.  \nPatient or Guardian Signature:   Date:    \nLast Review   Initials   Expiration of Form   **(Valid for 1 year for all proof of income, except Self-Declaration)  \nHorario de tarifa variable / formulario de verificación de ingresos  \nNombre del paciente:    \nPolítica: la tarifa variable se basa en dos factores: su ingreso y el tamaño de su familia en comparación con las Pautas federales de pobreza conocidas como su Porcentaje de pautas (\"PG\") . Si PG es igual o inferior al 100%, no pagará una tarifa. Si el PG está por encima del 100% y al 150% o menos, pagará el 25% del cargo publicado. Si el PG está por encima del 150% y al 200% o menos, será el 50% del cargo publicado. Si el PG está por encima del 200% y al 250% o menos, pagará el 75% del cargo publicado. Si PG está por encima del 250%, no es elegible para la tarifa móvil.  \nAgradecemos la oportunidad de brindarle servicios de salud. Es necesario que hagamos preguntas personales para darle un descuento en sus gastos. Esta información se mantendrá archivada en nuestro centro con estricta confidencialidad. Debe completar un Formulario de verificación de ingresos cada 12 meses o si hay un cambio en sus ingresos y / o el tamaño de su hogar. Para calificar para la escala de tarifa m","cbCaip1B5YIMOaJU","https://ap.wps.com/l/cbCaip1B5YIMOaJU","pdf",280978,"English","# Sliding Fee Schedule/Income Verification Form\n## Eligibility and PG-based fee tiers\n## Required income and documentation sources\n## Household income table and insurance information\n## Declaration, signature, and form validity","[{\"question\":\"How is the sliding fee calculated?\",\"answer\":\"The sliding fee is based on income and family size compared to Federal Poverty Guidelines, expressed as Percent of Guideline (PG). Fee eligibility and the patient’s percentage of the published charge depend on the PG bracket.\"},{\"question\":\"When is an Income Verification Form required?\",\"answer\":\"An Income Verification Form must be completed every 12 months, or whenever there is a change in income and/or household size.\"},{\"question\":\"What documents can be used to verify income?\",\"answer\":\"Acceptable proof includes paystubs, employer letters, tax returns, W-2s/1099s, Social Security award letters, disability or unemployment award letters, and other specified documentation such as child support verification or a self-declaration form for a first visit.\"}]","Sliding Fee Schedule/Income Verification Form - Protocol 2018 | PDF",1789488943]