FORM-Sliding Scale Application Sliding Scale Application To help determine if you qualify for financial assistance, please read, complete and submit this application form. 1. Review all information very carefully. 2. Complete all fields completely and accurately. 3. Gather and upload the required documentation. **Must send in two of the following options below** 1. Copy of last year federal income tax 2. Three most recent paystubs 3. All income statements from jobs last year (W2 or 1099) Note: Application can not be reviewed if any documentation is missing. All requirements are listed above in order to successfully complete the application review process. What happens after application has been submitted? *Please allow 3-5 business days for processing* You will be contacted by your preferred method of contact with a status update of your application submission and/or request for any additional or missing information that is necessary to complete your application. CEH reserves the right to refuse assistance to any applicant.Applicant Name:(Required) First Last Date of Birth:(Required) Home Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number:(Required)Email:(Required) Preferred Method of Contact:(Required) Phone Email Primary Language Spoken: English Spanish Other Marital Status:(Required) Single Married Divorced Is the applicant under 18 years old?(Required) Yes No If YES, then you must provide proof of income for the Parent or Legal Guardian in order for this application to be processed.If you are over age 18, are you financially dependent on someone else? Yes No If YES, then you must provide their proof of income for this application to be processed.Parent / Legal Guardian Name:(Required) First Last Parent / Legal Guardian Phone:(Required)Parent / Legal Guardian Email Address:(Required) Parent / Legal Guardian preferred contact method?(Required) Phone Email What is your total household gross income?(Required)Include yourself, your spouse, and your dependentsIs this gross income monthly or annual? Monthly Annual Number of people in the household?(Required)Please enter a number greater than or equal to 1.Employer(Required)For patient, or Parent / Legal Guardian if patient is under 18. Do you have insurance coverage?(Required) Yes No If yes, what type of insurance do you have?(Required) Member / Subscriber ID Number:(Required) Group Number(Required) Insurance Provider / Customer Service Number(Required)This is information is located on the back of your insurance card. Please read each of the following statements carefully, then indicate your understanding and agreement.Consent(Required)I give the program administrator and their employees, agents, and contractors permission to verify my information to make sure it is true and complete. I also give them permission to contact me about the program by phone, email, or mail. I understand and agree.(Required)Consent(Required)I promise that all the information in this application, including my proof of income, is true and complete. I am authorized to sign this application. I will contact the program if any of my information about my insurance or income changes. I understand and agree.(Required)Consent(Required)I understand that the program will only use my information to decide if I qualify to participate in the program. I understand and agree.(Required)Did someone other than the applicant complete this form?(Required) No Yes Consent(Required)I give the program and its administrators permission to contact the person named below with follow-up questions regarding my application. I understand and agree.(Required)Additional Contact Information:(Required) First Last Phone:(Required)Email(Required) Preferred Contact Method:(Required) Phone Email Electronic Signature:(Required)By typing your name below, you are signing this application electronically. You agree that your electronic signature on this application is the legal equivalent of your manual signature. Date:(Required) Supporting Documents:(Required)In order to process your application, you must submit TWO of the following: 1. Copy of last year’s federal income tax return 2. Three most recent pay stub 3. All income statement from jobs last year (W-1 or 1099) If the patient is a minor, then these proof of income documents must be from the Parent or Legal Guardian. NOTE: The application cannot be reviewed if any documentation is missing. I understand and agree.Federal Income Tax Return:Please upload your (or Parent / Legal Guardian) tax return.Max. file size: 25 MB.Paystubs:Please upload your three (3) MOST RECENT paystubs. Drop files here or Select files Max. file size: 25 MB, Max. files: 3. Income StatementsPlease upload ALL income statements from jobs last year (W-2 or 1099). Drop files here or Select files Max. file size: 25 MB, Max. files: 8. Δ
