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.

    I certify that my current total household income is and that I have no means of providing proof of such income with the sources required under ACH Sliding Fee Discount Policy for the following reason: My current total number of household members is Household Members

    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!