NOTICE TO PATIENTS

This practice serves all patients regardless of inability to pay. Discounts for essential services are offered based on the family size and income (Sliding Fee Discount Program).

For more information, ask the front desk or visit our website..

Thank you

AVISO PARA PACIENTES

Esta Clinica sirve a todos los pacientes, independientemente de la incapacidad de pago. Descuentos para los servicios eseciales son ofrecidos dependiendo de tamano de la Familia y de los ingresos (Descuento por tarifa deslizantes).

Usted puede solicitar un descuento en la recepcion o visite nuestro sitio de web.

Gracias.

Click Here to download or fill out the form below.

It is the policy of Swofford & Halma Clinic to provide essential services regardless of the patient’s ability to pay. Discounts are offered based on family size and annual income. Please complete the following information and return to the front desk to determine if you or members of your family are eligible for a discount.

The discount will apply to all Office Visits received at this clinic, but not those services or equipment that are purchased from outside, including reference laboratory testing, drugs, and x-ray interpretation by a consulting radiologist, and other such services. Ultrasounds and other office procedures will be discounted at 30% payment at time of service. This form must be completed every 12 months or if your financial situation changes.
Name of Head of Household
Place of Employment
Address
Street Address City State ZIP Code
Phone
Please list spouse and dependents under age of 18
Self
Date of Birth
MM slash DD slash YYYY
Spouse
Date of Birth
MM slash DD slash YYYY
Dependent
Date of Birth
MM slash DD slash YYYY
Dependent
Date of Birth
MM slash DD slash YYYY
Dependent
Date of Birth
MM slash DD slash YYYY
Dependent
Date of Birth
MM slash DD slash YYYY
Dependent
Date of Birth
MM slash DD slash YYYY
Dependent
Date of Birth
MM slash DD slash YYYY
Annual Household Income
Gross wages, salaries, tips, etc
Self
Spouse
Other
Total
Income from business, self-employment, and dependents
Self
Spouse
Other
Total
Unemployment compensation, workers’ compensation, Social Security, Supplemental Security Income, public assistance, veterans’; payments, survivor benefits, pension or retirement income
Self
Spouse
Other
Total
Interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources
Self
Spouse
Other
Total
Total Income
Self
Spouse
Other
Grand Total
Note: Copies of tax returns, pay stubs, or other information verifying income may be required before a discount is approved.
I certify that the family size and income information shown above is correct.
Name*
First Last
Email*
Date
MM slash DD slash YYYY

Please list spouse and dependents under age of 18

Annual Household Income

I certify that the family size and income information shown above is correct.

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