| Sliding
Scale Form Instructions:
These instructions are what we follow to determine eligibility and
level of assistance offered. |
| 1. The responsible
party is the adult in the family who will get the bills or letters,
if any need to be sent. This process is entirely confidential. |
| 2. On the
chart, "adults" usually refers to the parents although it could
be whoever is bringing up the children. Other adults might be a
grandparent or another person not usually considered part of the
nuclear family. If there are several adults living together ignore
the line labels and just put in their names and relationships. |
| 3. Convert the information on whatever
documents that you have into weekly or annual amounts. (See
Discount Tables) |
| 4. Children's after-school and weekend
jobs are not counted, but if they have a separate bill for health
insurance there is space for the amount. |
| 5. Get copies of the income & health
insurance documentation. Copy any & all insurance cards the family
has so that we can bill properly. If there is more than one, be
sure which is the primary carrier for which members of the family.
|
| 6. Check off any other insurance
types family members have. If it looks like a patient is eligible
for Medicaid, CHIPS or one of the company-sponsored indigent programs,
start the enrollment process. |
| 7. If there is insurance, we will
try to determine the amount due at the time of the visit; the patient
will owe the flat fee or the co-insurance, whichever is less. In
some cases we may have to send in an insurance claim to know. In
that case, the patient is sent a bill after the EOB is received. |
| 8. Determine the rate from the chart.
This amount is due at the time of the visit. There will not be other
charges unless you get medications for which we have to charge. |
| 9. The responsible person signs
the form. We will make you a copy for your records. |
| 10. We will send a postcard in a
year for a review, but if anything changes significantly before
then, please let us know. |
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8-04-00
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