Payment Information
To Make A Payment:
To make a payment: Please make your check payable to “The HealthCare Connection.” Include your account number in the memo section and mail your payment to 1401 Steffen Avenue, Cincinnati, OH 45215.
Annual Updating For Discount Services
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:
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At least 2 pay stubs from anyone working in the household
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W2
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Previous year's tax documents
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Notarized letters stating income from all sources
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Notarized 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.
Forms:
Income Sheet
Hoja de Ingresos
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.
Discount for Services Acknowledgment Documentation
Carta de Documentación para Servicios al Descuento
Decline of Discounted Services (No Discount)
Rechazo por servicios descontados (Sin descuento)