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Self-Declaration Form
Self-declaration may only be used in special circumstances. Patients who are unable to provide written verification must provide a signed statement of income, and why (s) he is unable to provide independent verification.
Name
*
First Name
Last Name
I certify that my current total household income is ($)
*
and that I have no means of providing proof of such income with the sources required under ACH Sliding Fee Discount Policy for the following reason:
*
My current total number of household members is
*
Number of individuals living within your home (including yourself)
Household Members
*
Name
Relationship to You
Age
Person 1
Person 2
Person 3
Person 4
Person 5
Person 6
Person 7
Person 8
Patient/Legal Guardian/Caregiver Signature
*
Please verify that you are human
*
Submit
Should be Empty: