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Sliding Fee Discount Application

Tribeca Pediatrics assures that no patient is denied healthcare due to their inability to pay. Our Sliding Fee Discount Program offers uninsured and underinsured patients discounts based on annual income and household size. The program follows Federal Income Guidelines to determine patient eligibility. Please review our Sliding Fee Schedule to see if you qualify. To remain eligible for the program, you must complete this form every 12 months or if your financial situation changes. If you have any questions, please call (212) 226-7666, option 3. 

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Applicant(Parent/Guardian) Information
Guardian's Name (First and Last) *
Guardian's Date of Birth *
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Current Address *
Phone Number *
Email Address *
Patient Information
Patient's Name *
Patient's Date of Birth *
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Does the patient have health insurance?  *
Required
Insurance Company and Policy Number
Please indicate the Tribeca Pediatrics location where the patient is seeking services *
Household Information
Please provide information for everyone living in your household and sharing income and expenses
List all members of your household (Name, Date of Birth) *
List monthly income before taxes for yourself and all members of your household (Include amount and source of income for each individual) *

Income Documentation- Required

Please email billing@tribecapediatrics.com proof of 30-day gross income for every member of the household contributing to income. 

Examples of proof of income include:
  • 2 most recent consecutive pay stubs 
  • Current Income Tax Return 
  • Child Support/Alimony Court Letter or Check Stub 
  • Self-employment records of earnings and expenses
  • Social Security Award/Benefit Letter
  • Proof of 1 month of rent income
  • Last 2 unemployment benefit checks
If you have no income, provide a letter of support or reference from an organization/individual and a signed statement of zero income.
Did you email the necessary documents to billing@tribecapediatrics.com? *
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