KCHC Sliding Fee Discount Program Application

KINSTON COMMUNITY HEALTH CENTER, INC. SLIDING FEE DISCOUNT PROGRAM APPLICATION

Please complete this application to apply for the sliding fee scale discount program. Make sure you answer all questions to avoid delays in your application being processed.
TODAY’S DATE

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
DATE OF BIRTH*

MonthDayYear
Date
PHONE NUMBER
EMAIL ADDRESS
example@example.com
Where do you live? *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your mailing address the same as your home address?*

Yes, I receive mail at my home address.No, I receive mail at and address that is different from my home address.
Where do you receive mail?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you live in public housing?*

YesNo
Are you homeless?*

YesNo
You answered that you are homeless. Where are you sleeping?

ShelterFamily Member's HomeAt a Friend's HomeStreetOther
Are you employed?

YesNo, I am unemployed.No, I am retired or disabled.
You answered that you are employed. Where do you work?
Do you receive unemployment benefits?

YesNo
Do you receive Social Security benefits?

YesNo
Do you receive retirement benefits?

YesNo
Do you receive any type of public assistance?*

YesNo
Do you receive alimony or child suport?*

YesNo
Are you a full time student?*

YesNo
Are you a seasonal or farm worker?*

YesNo
Who is your head of household?*

Self - I am my head of household.Someone other than myself. Provide head of household information below
Head of Household

HEAD OF HOUSEHOLD FIRST NAMEHEAD OF HOUSEHOLD MIDDLE NAMEHEAD OF HOUSEHOLD LAST NAME
Head of Household Date of Birth

MonthDayYear
Date
Is your head of household a patient at Kinston Community Health Center?

YesNoI Don't Know
How many people (including yourself) receive more than half of their financial support from your head of household?*

Family Information - Please complete the information for each family member in your household. Be sure to include your information on the first line and all family members including the head of household.

	Name of Family Member	Age	Employer/Income Source	Monthly Income
Patient
Family Member 1
Family Member 2
Family Member 3
Family Member 4
Family Member 5
Family Member 6
Family Member 7

Reported Monthly Income
Reported Annual Income
SUBMIT INCOME DOCUMENTATION

Please use the option for BROWSE FILES to attach documentation supporting the monthly income reported above.

Please use the option for TAKE PHOTO to use your device to take a photo of your income documentation and upload it to your application.

You may upload the last 2 paystubs, most recent tax return, or last two benefit statements for income such as Social Security and retirement income as proof of income. If these examples do not apply, please provide the most recent documentation of your income.

If you are unable to submit your income documentation online, please sign and submit the application and contact us at (252) 522-9800 and ask for Patient Access.
Cancelof
Take Photo of Income Documentation
The information that I have provided in this application is true and correct. I understand that Kinston Community Health Center will ensure this information will be protected as private and confidential. I understand this information will be shared with the US DHHS Health Resources and Services Administration (HRSA) for reporting purposes. I understand that I am responsible for reporting changes in my family size and/or income to Kinston Community Health Center, Inc.*

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