Please note: Only complete this form if you are in need of financial assistance to help cover your out of pocket health care costs. If this does not apply to you, please skip this form.
Please complete the following information for any other members of your household:
In order to qualify for the sliding fee, I am signing this letter which serves as a "Self Declaration" indicating that I have no income from any sources. I understand that I am responsible for my co-pay once I qualify for CHC's Sliding Fee. I fully understand the importance of reporting any income changes.
Please attach proof/verification for each of the income sources indicated above.
Type your name below to certify that the above information concerning my income is true and complete and that I have no income other than that listed above. I promise to notify CHC at once if there is a change in my income, family size, mailing address, or telephone number.