Raphara Health Sliding-Scale Application

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Raphara Health Sliding-Scale Application

Provided by the One Another Fund

Raphara Health does not discriminate or alter fee schedules based on health status, pre-existing conditions, or medical utilization.

Full Legal Name *

Date of Birth *

YYYY

Phone Number *

Email Address *

Current Address *

State of Residence *

Other:

Are you currently a patient at Raphara Health? *

Yes

Not yet, but I want to be

Have you previously qualified and obtained a sliding-scale membership through this application on prior years? *

Yes

Do you have active health coverage? (Select all that apply) *

Medicaid (Note: To become a member, you must sign an additional waiver)

Medicare (Note: To become a member, you must sign an additional waiver)

Employer Insurance / Private Insurance

Health Share Ministry

Uninsured

Required

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