Roanoke Rapids Sliding Fee Scale Application

Morse Clinic of Roanoke Rapids, PC SLIDING FEE SCALE APPLICATION

The Sliding Fee Scale is a method for providing reduced fees, based on a household’s size and income. In order to be eligible for this program, the following application must be completed, signed & dated, and submitted to the receptionist, along with proof of income (see listing on back side for acceptable forms of income)

Head of Household: Last_____________________________ First _______________________ Phone _______________ Mailing Address: __________________________________ City ___________________ State _________Zip ________

Have you or any of your household members applied for Medicaid in North Carolina? Yes  No 

SOURCES OF INCOME: All members living in the household. “Household” is considered all persons living with you at the same address. If living situation is temporary, please advise Morse Clinic staff of your situation.

Source	Amount ($)	Weekly	Bi-Weekly	Monthly	Annually	Staff Notes:
Salaries and Wages (self)					
Salaries and Wages (spouse)					
Salaries and Wages (other)					
Workmen’s Comp (SIIS)					
Social Security (Self/Spouse)					
Social Security (Children)					
SSI (Supplemental Security)					
Child Support / Alimony					
Military / Veterans Benefits					
Unemployment Benefits					
Other Family Members					

HOUSEHOLD SIZE: List all household members by NAME, DATE OF BIRTH, AND SOCIAL SECURITY NUMBER, include yourself:

NAME DATE of BIRTH	RELATIONSHIP SOCIAL SECURITY #
_____________________________________ _____________	________________	___________________
_____________________________________ _____________	________________	___________________
_____________________________________ _____________	________________	___________________
_____________________________________ _____________	________________	___________________
_____________________________________ _____________	________________	___________________
_____________________________________ _____________	________________	___________________
_____________________________________ _____________	________________	___________________
_____________________________________ _____________	________________	___________________
_____________________________________ _____________	________________	___________________

PLEASE READ THE FOLLOWING CAREFULLY

I declare that my household’s financial status is as listed above. I understand the following:

Morse Clinic of Roanoke Rapids is utilizing federal tax dollars to assist me in receiving health care
Giving false information regarding my household income is considered fraud against the U.S. government
Any change in my finances or the number of people in my household must be reported to clinic staff as soon as possible and a new application must be completed

Applicant’s Signature _______________________________________________ Date _________________________

You are required to provide proof of listed income in order to complete your application. The following are acceptable forms of income:

Current Federal Income Tax (1040-1040 EZ Form)
Paystubs for recent month
Current bank statement showing direct deposit (SS, SSI, SSD, Fip, Child support)
Printout from office issuing payments (SS, SSI, SSD, unemployment, VA, etc)
Pension payments, Veteran’s Benefits
Court order for alimony or child support or printout for child support payments
Employer statement for cash wages (must include employer name, address and phone number)
Award letter
Letter from caregiver

Office Use Only:

Guarantor #: ______________________

Application Received/Entered: Date: __________________ By: ____________________

	Yes	N/A	Notes:
Has patient or any household members applied for Medicaid/Medicare/other assistance?		
Unemployment Declaration Completed?		
Self-Declaration of Income Completed?		