sliding scale application form

Below, you will find different set of sliding scale applications. Although the actual form is the same, requirement and attachments for each category is different. Please choose the one that best describe your situation. Please be advised that incomplete application or failure to submit the required documents will result in the denial of your application. ALL REQUIREMENTS MUST BE RECEIVED WITHIN 30 DAYS OF APPLICATION.
EMPLOYED

Currently employed sliding scale applicants  must submit the following forms to be considered for Sliding Fee Scale Discount.
  • Sliding Fee Scale Application Form -  please fill out this form as complete and as accurate as possible. 
discount_schedule_eligibility_worksheet_website_-_final.pdf
File Size: 204 kb
File Type: pdf
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  • Sliding Fee Scale Employer Verification Form - the employer verification form must be given to your employer to complete. After it is completed, your employer may either fax it to us at (907) 581-2331, or you may submit it at the clinic. 
Employer Verification Form
File Size: 91 kb
File Type: pdf
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SELF EMPLOYED

Self employed sliding scale applicants must complete the Sliding Fee Scale Discount application and attache proof of income such as Income Tax Return.
  • Sliding Fee Scale Application Form -  please fill out this form as complete and as accurate as possible. 
discount_schedule_eligibility_worksheet_website_-_final.pdf
File Size: 204 kb
File Type: pdf
Download File
  • Proof Of Income -  such as Income Tax Return or any other type of document that shows your earning must be attached in the application. 
UNEMPLOYED

Unemployed sliding scale applicants must submit the following documents:
  • Sliding Fee Scale Application Form - please fill this form out as accurate and as complete as possible. 
discount_schedule_eligibility_worksheet_website_-_final.pdf
File Size: 204 kb
File Type: pdf
Download File
  • Circumstance Verification Form (CVS) - unemployed applicants must submit two (2) CVS forms from two (2) different individuals verifying the applicants current financial situation.  
Circumstance Verification Form
File Size: 63 kb
File Type: pdf
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