I understand that I will be required to provide proof of my household income on an annual basis. If I do not provide Neighborhood HealthSource with proper income verification I will not be eligible for the sliding fee discount. I agree to notify Neighborhood HealthSource of any changes in income, household size, or insurance status.
If I am determined to be eligible for the sliding fee discount:
I understand that I will be asked to pay a
flat rate fee
at the time of my visit. The flat rate fee will
cover the entire fee for the visit. The same day payment requirement applies to all patients
regardless of which category they are eligible for on the sliding fee scale.
I understand that I am responsible for any remaining balance due. If my account balance exceeds
$300, I will be asked to reschedule unless I am able to bring the balance below $300 and/or set up
a payment plan for the remaining balance. I understand that as long as I am making monthly
payments on my account that I will be able to see a provider.
Self declaration (PAC)
*Please note: Due to funding from various sources such as the government, we are required to have this form and proof of income on file.