Patient Name
    Marital Status:
    Veteran: YesNo
    Member ID:
    Group ID:
    Please list all children under 18 years of age who are Alliance Community Healthcare’s patients:
    Name Date of Birth Gender Relationship to above Individual Insurance Card
    ACCEPTANCE (required) ACCEPTANCE (required)
    ACCEPTANCE (required)

    Sliding Fee Discount Program Eligibility

    I am not interested in disclosing my financial information; therefore, my family and I are not eligible for the sliding fee discount program.Attached is my income documentation – tax records, pay stubs, employer letter, etc. (Please see attached Sliding Fee Application)I have no documentation to verify my income. (Please see attached Self-Declaration)

    Adult Consent and Acknowledgement of Services & ACH Policies

    Completion of this consent is necessary to offer services to a patient. Some items may not apply to your current visit, however in order to provide comprehensive care during this visit and future visits we request that you complete this content entirely. ACCEPTANCE (required)


    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:

    • We render our services on the basis that insurance companies may or may not pay for all, or a portion of our charges
    • Authorization for medical/dental treatment from your Insurance company does not guarantee full payment for the service
    • Not all Insurance Companies/third party payors pay for all services, each policy has its own particular stipulations regarding covered services, or amount of coverage.
    • All insurance companies state that verification of coverage is not a guarantee of coverage or payment.  Actual benefits are determined by your insurance company after a claim is received
    • Patients are personally responsible for knowing and understanding their own insurance policy, eligibility & coverage
    • Patient are responsible for payment of outstanding deductibles and Co-Insurance amounts at time of service.
    • Copayments will be collected at the time of service
    • Patients are financially responsible for payments of all non-authorized procedures and non-covered services
    • Changes in Insurance coverage must be reported to our staff promptly to avoid financial responsibility
    ACCEPTANCE (required)


    To ensure that each patient is given the proper amount of time allotted for their visit and to provide the highest quality care, it is very important for each scheduled patient to attend their visit on time. If it is necessary to reschedule the appointment, please call us immediately at (201) 451-6300. A reminder call to you is made/attempted the day prior to your scheduled appointment. A minimum of 24 hours cancellation notice is required for appointments. If you do not cancel in advance, and do not present to the office for your appointment, this will be considered a “No-Show: appointment. If you incur 3 “No-Show/Missed” appointments within one year, you will be charged a $25.00 fee and no longer will you be able to schedule appointments in advance without a $25.00 pre-payment for the visit. We value you as a patient and will do everything we can to accommodate you, so that you don’t incur any no show charge please be courteous and call if you are unable to keep your scheduled appointment. Our goal is to provide quality medical care in a timely manner. In order to do so we have had to implement an appointment/cancellation policy. The policy enables us to better utilize available appointments for our patients in need of medical care. ACCEPTANCE (required)


    What is an advanced directive?

    A written statement of a person’s wishes regarding medical treatment- this often includes a living well, made to ensure the patient’s wishes are carried out if the patient is unable to communicate them to a doctor.

    Appointment of a Health Care Representative/Proxy

    I, being of sound mind, willfully and voluntarily designate the following person as my health care representative to make any and all health care decision for me in the event that I become incapable of making decisions for myself. With this designation, I trust that this person will act in my best interest and in accord with my wishes.
    If the person I have named above is unable to act as my health care representative, I hereby designate the following person(s) to do so:

    If you are not completing an Instruction Directive/Living Will, please go to Part III (Signature and Witnesses) in this form. For more information regarding Advance Directives, please contact the Patient Services Manager.

    Health Care Instructions Directive/Living Will

    The following health care instructions directive exercises my right to make decisions concerning my health care. This directive is intended to provide clear and convincing evidence of my wishes to be followed in the event that I lack the capacity to make or communicate my treatment decisions. I, being of sound mind, willfully and voluntarily make known my wishes regarding my health care in the event that I can no longer make or communicate my decisions. If my health condition, as determined by my attending physician and at least one additional physician, fits nay of the following criteria: If I become permanently unconscious, If I have a terminal illness, If the life-sustaining treatment is experimental and not proven therapy or If I have a serious irreversible condition and the likely risks and burdens associated with the treatment would outweigh the likely benefits; or unwanted medical intervention would be inhumane, all the following statements are consistent with my wishes: (Please check all that apply) I do wantI do not want - Cardiac resuscitation. I do wantI do not want - Mechanical respiration. I do wantI do not want - Blood or blood products. I do wantI do not want - Kidney dialysis I do wantI do not want - Antibiotics. I do wantI do not want - Chemotherapy/radiation therapy. I do wantIdo not want - Simple diagnostic tests (blood work/x-rays). I do wantI do not want - Artificial or invasive forms of nutrition. I do wantI do not want - Artificial or invasive forms of hydration. I do wantI do not want - To make an anatomical gift of all or part of my body. If yes, specify: All organsOnly some organs Only this organs: I also direct that I be given all medically appropriate care necessary, including pain medications, to make me comfortable and to maintain my personal hygiene and dignity, even if they dull consciousness and indirectly shorten my life. ACCEPTANCE (required)


    SLIDING FEE OPTOUT I do not want the sliding fee

    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:

    1. Most current tax returns or W-2, All 1099’s
    2. Last two payroll check stub (gross income)
    3. Social security earnings (or other retirement or VA benefits), including unemployment and child support, court orders, welfare checks, workman’s compensation checks, etc.
    4. Letter from Employer/parent/caregiver if a patient does not file income tax returns and does not get paid with a check
    5. Bank statement showing earnings deposited for one month.
    6. Self declaration form (Self-declaration may only be used in special circumstances. Patients who are unable to provide written verification must provide a signed statement of income, and why (s) he is unable to provide independent verification).
    Please note that the federal poverty levels change annually which may impact your eligibility for the sliding scale fee discounted program.
    For office use only

    Income 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 Size: Family members who are considered for the eligibility criteria for Sliding fee program include the following individuals who live in the same household:

    • Patient, Spouse (including same sex marriage recognized by U.S. Jurisdiction)
    • Children up to age 21, Elderly parents/relatives that are being supported by the same household.
    Name Relationship Date of Birth Income type(sources) Annual Income $













    Do you have any type of insurance that will cover all or a portion of your medical expense? YesNo If yes, please list below and provide copy of insurance card to ACH Staff.
    ACCEPTANCE (required) [It's mandatory to accept all the ACCEPTANCE clauses]

    COVID-19 Boosters & Testing available at Alliance Community Healthcare. We also offer COVID-19 vaccines for children aged 5 and up.Call today at 201.451.6300!