Refuah Health Center is a Federally Qualified Health Center and is required to collect income information on all of our patients, regardless of whether a patient is insured or not.
Refuah may be required to disclose non-identifiable income information to the government, but your personal identifying information including name, address, date of birth, etc. will not be disclosed in connection your income information.
This form does not replace the sliding fee discount application. If you would like to see if you are eligible to receive a discount on services provided at the Center, you must complete a sliding fee discount application.
Refusing to disclose your income information will not affect your ability to receive services at the Center.
Family size includes anyone residing in a household and who share in the support and expenses of that household and/or are dependent upon that household. Family size may include individuals living outside the household as long as those individuals share in the support and expense of that household and/or are dependent on that household.
Please provide your family size:
Please provide your total household gross income: $
Please list your household’s annual gross income. “Gross income” means all income that your family receives before taking into account taxes and other deductions. Gross income includes all of your family’s wages, social security/disability benefits, alimony, unemployment and other public assistance. If you file the federal tax return form 1040A, your gross income can be found on Line 21. If you file the federal tax return 1040EZ form, your gross income can be found on Line 6. If you file the federal tax return 1040, your gross income can be found on Line 37. If you do not file a federal tax return for any reason, you can still enter your family’s gross income above.
Checking this box will not affect your ability to receive healthcare services at our Center.
By signing below, I attest that, as of the date of my signature, the above information is accurate.