THIS PRACTICE HAS ADOPTED THE FOLLOWING POLICIES FOR CHARGES FOR HEALTH CARE SERVICES
We will charge persons receiving health services at the usual customary rate prevailing in this area. Health services will be provided at no charge or at a reduced charge to persons unable to pay for services. In addition, persons will be charge for services to the extent that payment will be made by a third party authorized or under legal obligation to pay the charges.
We will not discriminate against any person receiving health services because of their inability to pay for services, or because payment for the the health services will be made under Part A or B of Title XVIII (“Medicare”) or Title XIX (“Medicaid”) of the Social Security Act.
We will accept assignment under the Social Security Act for all services for which payment may be made under Part B of the Title XVIII (“Medicare”) of the Act.
We will have an agreement with the State agency which administers the State plan for medical assistance under the Title XIX (“Medicaid”) of the Social Security Act to provide services to persons entitles to medical assistance under the plan.
Notice to Patients
This practice serves all patients regardless of ability to pay.
Discounts for essential services are offered depending upon family size and income.
You may apply for a discount at the front desk.
AVISO
ESTA CLINICA HA ADOPTADO LAS SIGUIENTES POLICAS PARA CARGOS DE SERVICIOS DE ATENCIÓN MÉDICA
Estaremos cobrando a personas recibiendo servicios de salud a la misma tarifa personalizada que prevalece en esta area. Los servicios de salud serán proporcionados sin costo o a un costo reducido a personas que no puedan pagar por los servicios. Adicionalmente, se cobrara a las personas por los servicios en la medida que el pago sera realizado por un tercer grupo autorizado o bajo la obligación legal a pagar los cargos.
No discriminaremos contra ninguna persona recibiendo servicios de salud basado en su inhabilidad a paga por los servicios, o porque el pago por los servicios de salud sera hecho bajo Parte A o B del Titulo XVIII (“Medicare”) o Titulo XIX (“Medicaid”) del Acto de Seguro Social.
Aceptaremos asignación bajo el Acto de Seguro Social por los servicios por los cuales el pago sera autorizado bajo Pate B del Titulo XVIII (“Medicare”) del Acto.
Tendremos un Acuerdo con la agencia del Estado que administra el plan del Estado para para asistencia medica bajo el Titulo XIX (“Medicaid”) del Acto de Seguro Social para proporcionar servicios a personas con derechos a asistencia medica bajo el plan.
Aviso a los Padres
Esta clinica atiende a todos los pacientes independiente de su habilidad de poder pagar.
Descuentos para servicios esenciales serán ofrecidos dependiendo en el tamaño de la familia y sus ingresos.
Podras aplicar por un descuento con las recepcionistas de entrada.
Dr. Miniyar’s Pediatrics
Sliding Fee Discount Program Application
It is the policy of Dr. Miniyar’s Clinic to provide essential services regardless of the patient’s ability to pay. Discounts are offered based upon family annual income and size. Please complete the following information and return to the front desk to determine if you or members of your family are eligible for a discount.
The discount will apply to all services received at this clinic, but not those services which are received outside of our office, including reference laboratory testing, drugs and other medications, x-ray interpretation by a consulting radiologist, and other such services that are not provided specifically at our office. In the hope that your financial situation improves, discounts only apply to current services. Application approval is only good for 6 months, at which point a new application with updated information must be submitted. Please inquire at the front desk if you have questions.
Patient’s Name and DOB: ________________________________________________
Number of related persons living in your household: ___________________
Name of Head of Household: ______________________
Place of Employment: ____________________________
Address (including city, state, and zip) _______________________________________________________________________
Please list 3 phone numbers: _____________________ ______________________ _____________________
Please list self, spouse, and all dependents under age 18.
| Name | Date of Birth | Name | Date of Birth |
| Self | Dependent | ||
| Spouse | Dependent | ||
| Dependent | Dependent | ||
| Dependent | Dependent |
Please list Annual Household Income in boxes below.
| Source of Income | Head of Household | Spouse | Other | Total |
| Gross wages, Salaries, Tips, Etc. | ||||
| Social Security, Pension, Annuity, and Veteran’s Benefits | ||||
| Alimony, child support, Military family Allotments | ||||
| Income from business self-employment, and dependents | ||||
| Rest, Interest, divided, and other income |
Total of all 5 boxes above: ______________
Verification Checklist. Please provide one or more of the following with application for each member of the household who supplies income:
- Previous year W2*
- 2 most recent pay stubs*
- Letter from Employer
- Form 4506-T (if W2 not filed)
- Self-Employed must provide most recent 3 months of income and expenses for the business.
* are preferred forms of income verification. Please supply both when possible.
I certify that the information show above is correct and understand verification is required for approval. I understand that supplying false information could result in termination of application and require payment of entire balance in full.
Name Print: ______________________
Signature: _______________________
Date: ___________________________
