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SFAP Application

Shawnee’s Financial Assistance
Program Application

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SHAWNEE HEALTH SERVICE

Because we are a Community Health Center, we have the opportunity to offer a discount on your services based on your family size and adjusted gross income.  This discount is available to all patients who are uninsured or under-insured.  If you feel this may be a benefit to you and your family, you will need to complete this Application and provide the following documentation.

REQUIRED:

  • Proof of Identification
    For all family members 18 and older seeking discount
  • Proof of Family Size
    Tax Return
    Attestation
  • Proof of Total Family’s Modified Adjusted Gross Income
    Tax Return
    – OR –
    4 Consecutive Paystubs
    Paid in Cash – Attestation
    Social Security/Disability Benefits
    Pensions (1099 or letter showing the amount)
    Workers Compensation
    Job Reimbursement
    Child Support
    Alimony
    Life Insurance
    Trust Fund
    Railroad Benefits
    Veteran Benefits
    Retirement Benefits

OPTIONAL:

  • Attestation – Patients may complete Attestation form to prove family size and income if they meet one of the following criteria:
    Unemployed adults supported by another adult
    Adults who work seasonally or intermittently
    Adults paid in cash
    Adults whose only source of income is SSA/Disability benefits
    Homeless
Family Members:
Your family is what you claim on your tax return.  Complete the table below.  Attach documents (birth certificate, divorce papers, marriage license) if there have been changes since the tax return.  If you are pregnant, please add “unborn child” to this list.  A copy of your tax return is required.  If you do not file tax returns, an Attestation Form is required – please ask for assistance.
 

Agreements:  By signing below, I agree that:

  • I certify that the information I provide is true and correct and that if the information proves to be incorrect, the discount will be denied.
  • I have completed and attached all required documentation.
  • I understand that it may take two business days to process my application.
  • I agree to inform Shawnee if there are changes to my income, household size, or insurance coverage.
  • I understand that certain services and/or items cannot be discounted.
  • I agree to pay a nominal fee at the time of services.
  • I understand an auditor of any patient assistance program that I may benefit from may review the information.
  • If receiving medication through the Pharmaceutical Assistance Program, I give permission to Shawnee Health Service and Development Corporation to sign patient assistance applications for me to order my medication.  This consent is valid as long as I am a patient of Shawnee Health Service and Development Corporation, or until I revoke my permission in writing.

Applicant Signature: __________________________________________________________  Date: _____________

Interpretation Provided By: _____________________________________________________________

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