Fee scale form 2026

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The document is a sample sliding fee scale form used to determine eligibility for discounted medical services based on household income and size. It includes sections for patient information, household income details, and various discount levels based on federal poverty guidelines. The form emphasizes the need for accurate income verification and outlines the consequences of providing false information.

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Click ‘Get Form’ to open the fee scale form in the editor.
Begin by filling out the 'Patient Information' section. Enter your first name, last name, date of birth, and contact details including home address and phone number.
Indicate your marital status and household size. List all household members along with their dates of birth and social security numbers.
In the 'Household Income' section, provide income details for yourself, spouse, and any children. Specify the amount and frequency of income (weekly, monthly, yearly).
Review the sliding fee scale options provided. Select the appropriate discount based on your reported income.
Finally, read through the declaration statement at the end of the form. Sign and date it to confirm that all information is accurate.

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