HCC Network

Sliding Scale Eligibility Form

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Name

Nombre

Apellidos

List of All Individuals Living in the Household (Please include full name, date of birth and monthly gross income) *Anyone that is living in the household or providing support for the household should be listed*:

Address:

City, State, Zip Code:

MONTHLY GROSS INCOME (EARNINGS BEFORE TAXES/DEDUCTIONS): **Documentation must be provided to determine eligibility for Slide Fee Scale** Acceptable Forms of Income Documentation include: 1) Current copy of Federal Tax Return (ALL PAGES) 2) Paystubs for the last 30 days 3) Social Security Benefit Letter 4) Disability Benefit Letter 5) Food Stamp Application Letter 6) Pension or Retirement Distribution Statements 7) Investment Statements 8) Unemployment Compensation Letter 9) Office Court Documents (Alimony, Child Support, etc.) 10) Letter from Employer documenting cash income 11) Completed Declaration of Income Statement 12) Any other source of income you may have. Please bring this with you to your first appointment!

Other, please explain:

Complete the information below only if you have no other way to document your income. All the boxes below must be checked, if applicable, and all questions answered. Failure to complete these questions may result in denial of your application. I do not have proof:

I do not get pay checks
I do not get pay stubs
I cannot get a letter from my employer. (Please explain why below)

I cannot get a letter from my employer. (Please explain why):

of incurred

Average Hours Worked Per Week?

Rate of Pay per Hour?

How Often Are You Paid in Cash?

Weekly
Bi-Weekly
Semi-Monthly
Monthly

I certify that I have no other way to document my income and that all the above information is true and correct. I understand that this information is to be used to determine eligibility for the Slide Fee Discount Program. I understand that HCC Network employees may verify the information on this form. I also understand that if I intentionally misrepresent my income, I may have to repay benefits received and may be prosecuted under State Law. (Please Type Name to Serve as Digital Signature):

I do hereby attest that this information is true, accurate and complete to the best of my knowledge. I have submitted or will provide proof of all household income listed on this application. I understand that completion of this application will not guarantee a discount. If I do not qualify for a discount, I agree to pay all incurred charges in full. If my income changes, I agree to provide HCC Network with current documentation of my income at my next appointment. I agree my income will be evaluated annually. I understand that if I qualify, my payment is due at the time of services based upon my assigned slide fee. I understand that dental labs, material and supplies prepared off-site ARE NOT included in the discount. (Please Type Name to Serve as Digital Signature):

Click here to view the sliding fee schedule.

Click on image to enlarge.

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