sliding fee discount program

All patients seeking health care services at HEALING WORD LLC are assured that they will be served regardless of ability to pay. No one is refused service because of lack of financial means to pay. This program is designed to provide free or discounted care to those who have no means, or limited means, to pay for their medical services (uninsured or underinsured). HEALING WORD LLC will not discriminate because payment for services would be made under Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP). HEALING WORD LLC will offer a Sliding Fee Discount Program to all who are unable to pay for their services.

HEALING WORD LLC will base program eligibility on a person’s ability to pay and will not discriminate on the basis of an individual’s race, color, sex, national origin, disability, religion, age, sexual orientation, or gender identity. The Federal Poverty Guidelines are used in creating and annually updating the sliding fee schedule to determine eligibility. (Guidelines and discount information are available upon request.)

Todos los pacientes que buscan servicios de atención médica en HEALING WORD LLC tienen la seguridad de que serán atendidos independientemente de su capacidad de pago. A nadie se le niega el servicio por falta de medios económicos para pagar. Este programa está diseñado para brindar atención gratuita o con descuento a quienes no tienen medios, o tienen medios limitados, para pagar sus servicios médicos (sin seguro o con seguro insuficiente). HEALING WORD LLC no discriminará porque el pago de los servicios se realizaría según Medicare, Medicaid o el Programa de seguro médico para niños (CHIP). HEALING WORD LLC ofrecerá un programa de descuento de tarifa móvil a todos los que no puedan pagar sus servicios.

Se puede solicitar una solicitud en español si es necesario.

If you would like to apply for a discount please fill out the following information. You will be required to provide Proof of Income (income tax return and/or last two pay stubs) to Healing Word LLC either in person or by mail. You may request this application in person at the office or via email.

***A sliding fee application CANNOT BE PROCESSED without proof of income***

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Name (head of household)

Date of Birth (for head of household)

Name of person(s) to receive services (if different)

Address (include city, state & ZIP)

County of Residence

Phone Number

Name of person who is employed

Employer/Company Name

Income (before taxes)

How often are you paid? (weekly, biweekly, etc.)

Other Sources of Income

• Alimony
• TANF
• Pension/Retirement
• Child Support
• Disability
• SSI
• Social Security
• Unemployment
• Other

Total Monthly Income from Other Sources

List the names of everyone living in the household including children and head of household.

Healing Word LLC realizes that the entire scope of individual situations cannot be visualized through your income information alone. We would like to give you the opportunity to explain any extenuating financial factors that may affect your ability to pay. Please include documentation of these expenses when you turn in your Proof of Income.

Electronic Signature (By placing my name below, I agree to provide Healing Word LLC with proof of income for the purpose of calculating my discount. I will be asked to reapply for the program on an annual basis. I certify that the income and family size information is true and correct. )

Date of Submission of Application

Submit