Sliding Scale Application
A completed application including required documentation of the home address, household income, and insurance coverage must be on file and approved before a discount will be granted. If the applicant appears to be eligible for Medicaid, a written denial of coverage by Medicaid may also be required.
Email *
Applicant Name: *
Applicant Phone Number: *
Applicant Address: *
Annual Income of Applicant & Spouse: *
Include income from all sources, including gross wages, tips, social security, disability, pensions, annuities, veteran’s payments, net business or self-employment, alimony, military, child support, unemployment, and public aid.
Number of Persons Living in Your Household: *
Number of Dependent Children Under the Age of 18: *
By submitting this form you certify that the family size and income information shown above is correct. Copies of tax returns, pay stubs, and other information verifying income may be required before a discount is approved.
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