Shaw Family Medical Sliding Fee Discount Application
  Sliding Fee Discount Information It is the policy of Shaw Family Medical to provide essential services regardless of the patient’s ability to pay. Shaw Family Medical offers discounts based on family size and annual income. Please complete the following information and return to the front desk to determine if you or members of your family are eligible for a discount. The discount will apply to all services received at this clinic, but not those services or equipment purchased from outside, including reference laboratory testing, drugs, and x-ray interpretation by a consulting radiologist, and other such services. You must complete this form every 12 months or if your financial situation changes.  
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NAME OF HEAD OF HOUSEHOLD *
STREET *
PLACE OF EMPLOYMENT *
CITY *
STATE *
ZIP *
PHONE *
Please list spouse and dependents under age 18 with their date of birth. *
Which dependent are you filling this form out for? *
Where is your source coming from ? *
Required
Whats the total income based on your sources? *
  NOTE: Copies of tax returns, pay stubs, or other information verifying income may be required before a discount is approved.  Do you agree to provide this information if needed?
 *
  I certify that the family size and income information shown above is correct. Please sign your name .   
 *
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