SLIDING FEE APPLICATION - HORIZON HEALTH CARE, INC.

The Sliding Fee Scale is a method for providing reduced fees, based on a household's size and income.  In order to be eligible for this program, the following application must be completed and submitted along with TWO most current pay stubs for all adults in the household, last year's income tax return, or proof of all income received by adults in the household.  

Household Information

  Name (First Name, Middle Name, Last Name) Relation to #1 Date of Birth

Sex (M, F)

Social Security Number
1.

Self

2.
3.
4.
5.
6.

Contact Information

Mailing Address                                                              City State Zip County
Home Phone # Work Phone # Cell Phone #

Sources of Income: List all the income received by adults living in your household (related and unrelated)

Source Amount Weekly Bi-weekly Monthly Annually
Salaries and Wages (self)
Salaries and Wages (spouse)
Salaries and Wages (other)
Pension Plan/ retirement
Workmen's Comp
Social Security (self/spouse)
Social Security (children)
SSI (supplemental security income)
Child Support / Alimony
Interest Income
Military / Veteran's Benefits
Unemployment Benefits
Public Assistance
Other

I, the undersigned, have completed this application for Sliding Fee eligibility and, by hitting the "Submit button, confirm that this information is true and correct, to the best of my knowledge. I understand my eligibility will not be affected by my race, color, national origin, age, disability or sex. I further understand that any change in financial status or the number of people in my household must be reported immediately to Horizon Health Care Inc (HHC), and a new application must be completed. I understand that I need to complete a new form annually and provide verification of income. I understand any falsifications or the failure to report any changes may result in my being made ineligible for the Sliding Fee adjustments made available by HHC.


Author information goes here.
Copyright � 2007 [Horizon Health Care, Inc.]. All rights reserved.
Revised: 02/01/07