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Self-Declaration Form (English)

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  • Self-Declaration Form (English)

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

    About us

    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.

    Visit us

    • 115 Christopher Columbus Dr.
      Suites 100 & 101
      Jersey City, NJ 07302
    • Phone
      (201) 451–6300 (after hours, option 8)
    • Fax
      (201) 451-0619

    Accreditations


    • Federally Qualified, Accredited Health Center
    • Recognized by the NCQA for our Patient-Centered Medical Home Care
    • Alliance Community Healthcare is an FTCA deemed website.
    • HCQL 2020Quality Improvement Award Recognition

    Non-discrimination Statement

    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.

    Read the complete  statement.

    © 2019 Alliance Community Healthcare, Inc.
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