Name (First, M.I., Last)
Social Security Number (Optional)
Date of Birth
County
Address including apt number or unit number
City/State/Zip
Home/Cell phone
Work Phone
Number of People in the home
Marital Status: S=Single M=Married W=Widowed D= Divorced S=Separated
All Employed People in the House: Name/Company Name/Income (before taxes)/How often paid?
continued..
List all individuals in the household including DOB/ Relationship/Age/Income/ Employment status
Typed Signature <br/>By signing above, I agree that the Fordland Clinic staff may contact each employer listed and or other agencies to confirm my income. I will provide FC with proof of income for the purpose of calculating my discount. I will be asked to re-affirm on an annual basis. I agree to inform FC 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 my copay at the time of services. I hereby certify that the information I provide is correct.
Please make sure to bring your income in the form of income taxes for the previous year to your appointment.