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Click ‘Get Form’ to open it in the editor.
Begin by entering your full name, email address, mailing address, and phone number. Indicate whether you would like detailed messages left at this number.
Select the appropriate checkbox to indicate the purpose of completing this form—either for household information for grants or to apply for a sliding fee scale discount.
In the household information section, list all members of your household along with their relationship to you, date of birth, health insurance status, employment status, gross monthly income, source of income, and tax dependency status.
On the back side of the form, check off which documents you will provide as proof of income. Ensure that you have one document for each source listed.
Finally, review your information for accuracy and sign the form. Initial where required to give permission for Unity Care NW’s Enrollment Specialists to access your income information.

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How to calculate a sliding fee scale?

How to create a sliding fee scale for your healthcare practice Step 1: Determine usual and customary healthcare fees. Step 2: Calculate your operating expenses. Step 3: Define your desired salary. Step 4: Identify your minimum monthly income requirement. Step 5: Estimate your average monthly patient volume.

What income qualifies for sliding scale?

PAY LESS ON THE SCALE IF YOU: you are supporting yourself or your family on a minimum wage. are chronically scarce and have more difficulty finding employment or earning higher income due to level of education, racial privilege, disability, gender, class background, etc.

What does sliding scale mean for insurance?

Example of Sliding Scale Fees The average cost of a patient visit is $500. The hospital has implemented a sliding scale fee structure for treatment. The cost per patient visit will vary from $100 to $700 based on the specific incomes of the patients. The lowest income earners pay $100 and the highest pay $700.

What does sliding scale mean in medical terms?

A sliding fee scale for health care is a way to adjust the cost of medical services based on a persons income. Its essentially a discount system that changes the amount you pay depending on how much money you earn. If you earn less money, youll pay less for medical services.

What is the sliding fee scale for health care?

A sliding fee scale for health care is a way to adjust the cost of medical services based on a persons income. Its essentially a discount system that changes the amount you pay depending on how much money you earn. If you earn less money, youll pay less for medical services. If you earn more, youll pay a bit more.