Patient Registration Form

As a Federally Qualified Health Center (FQHC) system, FCCH is required to offer a sliding fee discount for our patients who are unable to pay the full charges for care. First Choice receives grant money to assist those of our patients who qualify for a discounted fee for office visits and most procedures performed in our facilities. Depending on a patient’s family size and income, patients may qualify to receive services at a reduced rate. Income grids are updated every year, according to federal guidelines.

Proof of income is required for all patients who do not have insurance and who want to apply for the sliding fee discount program to possibly get a reduced charge for the services they receive. However, all patients will be asked if they would like to provide proof of income for the discount, even if they have private insurance; many times, a patient’s insurance deductibles are very high or their insurance may not pay for all services provided. After the insurance company pays and if the patient qualifies for the discount by providing income documentation, FCCH/Central Billing can apply the discount to the patient’s balance. Discounts cannot be applied after the fact: current income documentation must be in place for the date of service for which a discount is sought.

This is a federal government program and if any of the above data is false it may lead to being denied future slide (discount) options. First Choice can assist our patients with application for Medicaid and/or other health insurance or healthcare funding programs. If you would like to apply, please ask us to help!

Sliding Fee Documentation Process
All patients seeking consideration for sliding fee discounts must provide documentation. Without one of the following forms of documentation, uninsured patients will be expected to pay at least the nominal visit fee at the time of service and will be billed for the remainder of the full charges, with no discount applied.
       

           If a first visit with us and you are unable to provide any proof of income for this date of service, First Choice can offer the One Time Affidavit, which would allow a personal attestation as proof of income for a sliding fee discount. The One Time Affidavit will ONLY be valid for ONE DAY, and will not be renewed at any other point throughout your care with us.
         

       For one (1) year of sliding fee eligibility, any one of the following “official” income documentation examples is considered acceptable; please note that documentation is needed from all household members who contribute to the household income:

• A tax return with W-2 and/or 1099s from the prior year; total gross income is used to calculate income (Note: After April 15 of the current year, the return MUST be for the year that just ended.)
• Check stubs for the prior month (Note: if paid weekly, requires 4 consecutive stubs; if paid bi-weekly, requires 2 stubs; monthly, just one) – gross wages are used calculate income
• A signed employer statement (on company letterhead), confirming (gross) wages and frequency of pay
• Check stubs, bank statements (for auto-deposits) or an authorized letter reflecting participation in/specified compensation benefits from a recognized benefits program (SSI, Social Security, VA or other pension, unemployment benefits, etc.)
• If you are not employed and support is being provided by someone else, please request the separate form “Letter of Financial Support”, which must be completed, signed and notarized, and returned.