Income Verification Form EngSpan Mar2015
Medicaid is the only insurance carrier accepted.
Please visit clinic #10 in order to check if you are eligible and apply.
If you do not have insurance, you will be charged based on a sliding scale fee derived from your household income. In order to receive the sliding scale fee, you must bring Proof of Income within 30 days of your first visit.
Proof of Income can include:
· Current Paystub
· W-2 Form
· Letter from Your Employer Stating Your Gross Income Income Verification Form
If you fail to provide Proof of Income, you will be billed at 100% for each clinic visit.
No one will be refused services due to citizenship status or inability to pay.