VERIFICACIÓN DOCUMENTADOS DE INGRESOS / Fecha__________ TAMAÑO DE LA FAMILIA (Attach copies of proof of income, such as paycheck stubs, income tax returns, etc.) Always make copies, never hand over originals you may need for use later. INGRESOS TAMAÑO DEL HOGAR UNA MUJER EMBARAZADA CONTARÁ COMO DOS EN EL HOGAR COSTO CORREDERA Yo certifico que la información que he dado es correcta, a lo mejor de mi conocimiento. Entiendo que voy a ser responsable de las consecuencias (por ejemplo, pagos, multas, acciones legales, etc.) resultantes de información falsa. Firma del paciente Fecha WHITESIDE COUNTY COMMUNITY HEALTH CLINIC 2014 TAMAÑO DE FAMILIA 100% descuento Paga $25* 80% de descuento Paga 20% 60% de descuento Paga 40% 40% de descuento Paga 60% 20% de descuento Paga 80% 0% descuento Paga 100% 1 $0-11,670 $11,67114,588 $14,58917,505 $17,50620,423 $20,42423,340 $23,341 2 $0-15,730 $15,73119,663 $19,66423,595 $23,59627,528 $27,52931,460 $31,461 3 $0-19,790 $19,79124,738 $24,73929,685 $29,68634,633 $34,63439,580 $39,581 4 $0-23,850 $23,85129,813 $29,81435,775 $35,77641,738 $41,73947,700 $47,701 5 $0-27,910 $27,91134,888 $34,889 41,865 $41,86648,843 $48,84455,820 $55,821 6 $0-31,970 $31,97139,963 $39,96447,955 $47,95655,948 $55,94963,940 $63,941 7 $0-36,030 $36,03145,038 $45,03954,045 $54,04663,053 $63,05472,060 $72,061 8 $0-40,090 $40,09150,113 $50,11460,135 $60,13670,158 $70,15980,180 $80,181 Por cada miembro adicional de la familia +$4,060 CHC Población objetivo a 100% de la pobreza a 125% de la pobreza a 150% de la pobreza a 175% de la pobreza a 200% de la pobreza *Mínimo $ 25, Médico, Dental y Salud Mental Firma del entrevistador (Interviewer’s Signature) CHC Forms – Documented Verification of Income Family Size – Spanish - 2014 200% de la pobreza PROOF OF INCOME WORKSHEET Patient name ___________________________________ If they get paid biweekly take gross amount add it together, total amount divided by 2 then times 26. Number of people in household____________________ Total amount _________________ Enter gross amount _________________ _________________ Amount divided by 2 ____________ Amount times 26 ______________ This amount is your yearly income _________________ _________________ If they get paid weekly take gross amount add it together, total amount divided by 4 then times 52. If they get paid bimonthly take gross amount add it together, total amount divided by 2 then times 24. Total amount _________________ Total amount _________________ Amount divided by 4 ____________ Amount divided by 2 ____________ Amount times 52 ______________ This amount is your yearly income Amount times 24 ______________ This amount is your yearly income Completed By________________________ Date______________________________ DISCOUNT SLIDING SCALE FEES ELIGIBILITY CRITERIA The Whiteside County Community Health Clinic is a federally qualified health center that provides primary and preventative health care services to individuals who have limited access to health care due to the lack of financial resources or health insurance. To ensure that income or lack of insurance is not a barrier to care, low-income patients who are not covered by public or private insurance are charged on a sliding fee scale. 1. The Clinic uses the Federal Poverty Income level guidelines to determine the discount the patient will receive based on their income and family size. 2. If a patient wishes to be evaluated for the Clinic’s sliding fee scale, they MUST bring information regarding their house hold income with them when they come to their initial appointment. Patient will be charged full fee until proof of income is provided. Patient will be charged full fee until proof of income is provided. 3. To continue to qualify for sliding fees, the patient will need to bring income information once a year. ACCEPTABLE FORMS OF PROOF OF INCOME: See the “Income Verification for Sliding Fee Discounts” policy and the “Protocol for Income Calculation for Documented Verification of Income/Family Size Form.” CHC Forms – Documented Verification of Income Family Size – Spanish - 2014