The purpose of this financial agreement is to help Alliance patients understand about medical/dental insurance, eligibility, coverage, and our office policy and services.
It must be understood that:
Qualifications for the sliding scale fee discount program are based on gross annual income and family size compared to the federal poverty levels. You are required to provide ACH with proof of income and a complete application prior to your second visit. If documentation is not provided by the second visits, the patient will be considered 100% self-pay. You must verify your income and family size at least annually or notify when changes occur if sooner. Payment of your nominal amount of flat rate is expected at the time of service. See ACH SFDP policy. The acceptable forms of proof of income are:
Income will be defined as ALL sources and forms of revenue/earnings/funds (before taxes/gross/total income, e.g. line 22 of Form 1040/line 15 of Form 1040A/adjusted gross income line 4 of 1040EZ and Line 7 for 2018 redesigned 1040 (adjusted gross income or AGI)) (For Tax Year 2018, you will no longer use Form 1040A or Form 1040EZ) earned or received by an individual or family. Examples of income include but are not limited to: self-employment earning (net of business expenses), unemployment, gross employment earnings, tips, child support, alimony, interest, dividend, retirement/pension or social security income, student support income, welfare or other public assistance payments, veterans payments, survivor benefits, pension or retirement income, rental income, royalties, income from estate or trusts, educational assistance, assistance from outside the household, and other miscellaneous source, etc. Non cash benefits (such as food stamps and housing subsidies) do not count and income excludes capital gains or losses.
Family members who are considered for the eligibility criteria for Sliding fee program include the following individuals who live in the same household:
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Alliance Community Healthcare was founded in 1963. Today we deliver comprehensive healthcare services to more than 19,000 patients and handle more than 58,000 outpatient visits annually.
We offer primary care, women’s health, family care, dental services, pediatrics, and more.
Alliance Community Healthcare complies with applicable Federal Civil Rights Laws and does not discriminate or exclude people on the basis of race, color, national origin, age, disability or sex.
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