Denial Forms

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Denial Forms2019-09-05T11:37:08-04:00
  • If you do not wish to be assessed for the Sliding Fee Discount Program, the Medical Office Clerk will ask that you sign the following at intake:

Family Medical Care offers a sliding fee discount program to ensure that no one will be denied access to health services due to their inability to pay. The program allows FMC to reduce fees for the care of you and or your family. Eligibility is based on family size and income, and must be verified through our Customer Service Coordinator.

Do you wish to apply for the program?

Patient declines to participate in the sliding fee discount program.

 

  • Family Medical Care is a Federally Qualified Health Center. As such we are required to ask all patients for their household size and income. You will be asked at intake if you are willing to share this information. If you wish to decline providing this information, you will be asked to sign the following:

Family Medical Care is a Federally Qualified Health Center. As such we are required to ask all patients for their household size and income. Are you willing to share this information? I decline to share my household income and size at this time.