In order to receive discounted services, all patients must file an agreement for discounted services (See Below). This form must be filed ANNUALLY in order for discounts to continue. Patients must bring this form along with one of the following documented proof of income (POI).

Types of Proof of Income Documents:

  • At Least 2 Pay Stubs from anyone working in the household
  • W2
  • Previous Year Tax Documents
  • Notorized letters stating income from all sources
  • Notorized document(s) from employers, family members or anyone providing support

If all documentation is not provided at the time of care patients may not be eligible to receive discounted services.

Also, services are not retroactively discounted. All services provided to patients must be paid for in full.

Form for Discounted Services:

In order to receive discounted services the following form must be filled out. Patients can print and fill out information at home, or can elect to fill out all forms at the time of visit. Filling forms out before the visit will speed up the length of time it takes to see the provider.

English: Discount for Services Documentation Acknowledgement

Español: Discount for Services Documentation Acknowledgement – Spanish

 

Declining Discounted Services:

Patients who are either ineligible for discounted services, or elect to pay the full amount must fill out the following form. Patients can print and fill out information at home, or can elect to fill out all forms at the time of visit. Filling forms out before the visit will speed up the length of time it takes to see the provider.

English: Decline of Discounted Services -No Discount

Español: Decline of Discounted Services -No Discount – Spanish