Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.OhioGuidestone Health Center - Sliding Fee Discount Application It is the policy of OhioGuidestone Health Center that patients will not be denied health care services because of their inability to pay. Discounts are offered based on household size and annual income. This discount will apply to all services received at OhioGuidestone Health Center. For required services offered through a formal referral arrangement, patients will rely on that provider's sliding fee scale. Patients must supply proof of income prior to their next visit or within 30 days, whichever is sooner, or you will be responsible for the full charge. Declare Interest *I am interested in disclosing my financial information and being screened for the sliding fee discount program.I am not interested in disclosing my financial information; therefore, my family and I are not eligible for the sliding fee discount program.Patient InformationToday's DatePatient Name *FirstMiddleLastPhone *Phone Type *HomeCellWorkDate of Birth *Social Security Number *Home Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCheckboxesMy mailing address is the same as my home addressMailing AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDo you have insurance? *YesNoNot SureInsurance NamePolicy NumberHousehold Size Please list all household members, including yourself. Click the small + icon next to "Relationship to Patient" to add additional household members.Total Household Size Household Member Name *FirstLastDate of BirthRelationship to Patient Add Remove Sources of Income Please add monthly income amounts for each member of the household to each type below.Gross wages, salaries, tips, etcSelfSpouseChildren/OtherTotalSocial Security, pension, annuity, veteran's benefitsSelfSpouseChildren/OtherTotalAlimony, child support, military family allotments Address (copy) Gross SelfSpouseChildren/OtherTotalIncome from business, self-employment, dependentsSelfSpouseChildren/OtherTotalUnemployment, workers' compensation, etcSelfSpouseChildren/OtherTotalRent, interest, dividends, and other incomeSelfSpouseChildren/OtherTotalTotal Monthly Household IncomeI have reviewed this form and certify that the information I provided is true and correct to the best of my knowledge. I understand that I will be charged the full fee of my visit if I do not bring in documentation of income by my next visit or within 30 days, whichever comes first. I agree to notify the health center if there are any changes in my household income, size, or if I receive health insurance benefits including Medicare or Medicaid. Failure to report any changes may result in dismissal from the Sliding Fee Scale and my account will be adjusted as such. I agree to pay any outstanding balances and understand that payment plans are available to me.Patient Signature Clear Signature Guardian Signature (if applicable) Clear Signature Submit
