Complete if patient is under 18 years old, otherwise, please click Next Page at the bottom to continue
Click here to download and print the sliding fee discount application
Since Goodwin Community Health receives both state and federal funds, you and your family may be eligible for a discount on the fees charged for services and supplies you receive. This discount is based on family size and household income. If you wish to apply for a discount, you will need to answer the questions below and supply proof of income 30 days from the date this application is signed. If you are applying for our sliding fee, once proof of income is received, you will be eligible for that discount for one year.
The following are appropriate examples of types of income:
The following are appropriate examples of proof of income:
The above information supplied is current and accurate to the best of my knowledge. Should inaccurate information be provided, any discount given will be reversed based on this information.
Your answers on this form will help your health care provider better understand your medical concerns and questions. If you are uncomfortable with any question, do not answer it. If you cannot remember specific information, please provide your best guess. Thank you.
Please indicate whether you have had any of the following medical problems
HOME & FAMILY
Please complete if your child is 17 or younger: