Income tax returns for the past year with W2’s and Schedules
OR Three (3) most recent paycheck stubs for each working member of the family
OR Unemployment check stub or the determination letter
Workerman’s Compensation (SSI) Income
SSI (Supplemental Security) Income
Full time student documentation (verification letter from school with credit hours and expiration date)
Patients who fail to produce the appropriate documentation for the Uninsured Sliding Fee Schedule will be informed that they are 20% pay patients. Any patient, who fails to provide the required documentation at their next visit will be required to pay full price.