Sliding Fee Dental Determination Form Eligibility Determination for Sliding Fee Discount Thank you for your interest in the Sliding Fee Dental Determination Form. If you are applying for a sliding fee discount of indigent medications, please furnish proof of income by supplying a copy of last year’s tax return. You will have 7 days to supply proof of income. If not provided within this time, full charges will apply. Without proof of income, your application will not be processed and your enrollment into the program will be delayed. Additionally, If there are special issues you feel should be considered when we review your application, please include those in the designated area of this application. If you do not have any income to report, please complete the Zero Income section below. All income changes must be reported to the clinic. This application is good for 1 year before you will be asked to reapply. Household Members Zero Income Please explain how your basic needs have been met. (Food, Utilities, Shelter, Non-Food Items, Clothing) I, , certify that I have no source of income. Application Finalization All applicants, PLEASE READ THE FOLLOWING STATEMENT, CHECK A BOX AND THEN SIGN BELOW. I agree to be responsible for my St. George Medial Clinic bills. I agree to inform the St. George Medical Clinic of any changes to my income. I certify that the information I have given on this application is complete and true. Below Poverty100% - 133%134% - 150%151% - 199%Over 200%
