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PDF Sierra Vista Community Health Center - Sliding Fee Scale Application 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the 'Name of Head of Household' at the top of the form. Ensure accuracy as this information is crucial for processing your application.
- Fill in your 'Address', 'State', 'City', and 'Zip' code. This helps establish your residency and eligibility for services.
- Provide a contact 'Phone' number where you can be reached for any follow-up questions regarding your application.
- List yourself, your spouse, and all dependents under age 18 in the designated section. Include their names and dates of birth to ensure proper family size assessment.
- In the income section, detail all sources of income for yourself and your spouse. Be thorough in listing gross wages, self-employment income, unemployment compensation, and any other relevant financial support.
- Review the certification statement at the bottom of the form. Sign and date it to confirm that all information provided is accurate.
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(928) 583-1000 Primary Care, Dental, Sierra Health Center (623) 546-4410 Primary Care, Dental, Mental Health (602) 389-3560 Primary (928) 681-8705 Primary Care
Community Health Center Clinica Sierra Vista (559) 457-6900. Sliding scale of fees based on income. (661) 854-3131 (661) 324-1455. Sierra Vista 559-457-5600.