Family/Dependent Sliding Fee Discount Application

Family/Dependent Sliding Fee Discount Application
Please complete for each member of your family/dependants (start with head of household)
Name: Head of household

First NameLast Name
Date of Birth
Relationship
Employed?
Additional Family/Dependants

Note: If you have more dependents than this form provides, please call registration at (612) 872-8086 to complete this application.
Name

First NameLast Name
Date of Birth
Relationship
Employed?
Name

First NameLast Name
Date of Birth
Relationship
Employed?
Name

First NameLast Name
Date of Birth
Relationship
Employed?
Name

First NameLast Name
Date of Birth
Relationship
Employed?
Name

First NameLast Name
Date of Birth
Relationship
Employed?
For informational purposes only
I have applied for MinnesotaCare and/or Medical Assistance:
Date applied:
Do you feel NACC's sliding fee scale is affordable?
I have listed all of my family’s income to the best of my knowledge.
- I will notify the clinic if I become eligible for any form of health insurance.
- I agree to provide proof of income* at time of service (or at maximum within 60 days) and every 12 months thereafter or I will be billed and will pay 100% of the charges. I understand that there will be a charge for all services and the amount I must pay depends on the services I receive and the sliding fee discount that I may be eligible for.
- I understand that I am expected to make a minimum payment equivalent to the applicable nominal fee at each visit; and that I will be billed for the balance. Nominal fees are $10 for Counseling visits, $15 for Medical & $50 for Dental.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Upload Proof of Income Documents

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*Acceptable proof of income includes: Your two most recent pay stubs, workers compensation or unemployment benefits notification letter, tax return if self employed, or in unusual circumstances, other written documentation of your earnings (Attestation Form or other) subject to approval.

YOU MAY REQUEST A COPY OF THE POLICY AT ANY TIME
Should be Empty:

Family/Dependent Sliding Fee Discount Application

Additional Family/Dependants