Sliding Fee Application

GHC Sliding Fee Application

Sliding Fee Application

Dear Applicant,

Genesis Healthcare, Inc. invites you to apply for our Sliding Fee Program. We are dedicated to providing quality health care at affordable prices to residents of our community. Eligibility for the program is based on several factors, including your annual household income and the family size of those living in the household. Please fill out the attached paperwork in full and return it to us with the necessary documentation (listed directly under the “Application – Patient and Family Member Details” Section). All information provided will be kept on file and in strict confidence.

Completed applications will be processed, and a letter with your discount determination will be mailed to you. If your application is denied, we will mail you a letter with an explanation of denial. Missing information or incomplete applications will place the application on hold until we receive all necessary information to determine the appropriate discount level. To continue to qualify, you must verify family household income and size on an annual basis. If you have any questions, please feel free to call (843) 393-7452 during normal business hours and ask for a Financial Counselor. Thank you for your cooperation in turning in a complete application so that we may help you obtain financial assistance for your healthcare services here at Genesis Healthcare.

Application Instructions:
1. Complete the “Application – Patient and Family Member Details” Section of the application in full.
2. List all members of your household and provide either:
o The most recent one month of income, or
o The previous calendar year’s income for each household member.
3. If any household member has no income, please enter $0 for that individual.
4. Submit income documentation by:
o Emailing it to: financialcounselors@genesisfqhc.org, or
o Mailing it to the Genesis location where you are receiving care.
5. For questions regarding application process or acceptable income, please call 843-393-7452 and ask for a financial counselor, or email financialcounselors@genesisfqhc.org.

Sincerely,

Genesis Healthcare, Inc.

General

Select GHC Location

Please select your GHC office

Application - Patient and Family Member Details

Proof of acceptable income includes but is not limited to your yearly income tax return (must be completed), copy of your last month’s paycheck stubs, current bank statement showing direct deposit. If you do not have the prior proof, you may sign the Patient Financial Self-Attestation Agreement.

Patient First Name

Patient Middle Name

Patient Last Name

Patient Address

Patient City

Patient State

Patient Zip

Patient Phone

Patient Date of Birth

Have you applied for medical assistance?

Do you or any family member of your household receive Medicare Extra Help or any other type of low-income subsidy?

If no, would you like assistance in applying for any extra help?

Family Member

To Be Completed by Patient/Guardian for EACH family member of the household

1.

Name

DOB

Relationship

Relationship Other

Income Verification Method

Income Verification Other

If you have multiple income verification methods to list or do not see your type of income verification method listed, please enter the information in this 'Other' field.

Income Frequency

Income

Number only

GHC Patient?

Account Number

2.

Name

DOB

Relationship

Relationship Other

Income Verification Method

Income Verification Other

If you have multiple income verification methods to list or do not see your type of income verification method listed, please enter the information in this 'Other' field.

Income Frequency

Income

Number only

GHC Patient?

Account Number

3.

Name

DOB

Relationship

Relationship Other

Income Verification Method

Income Verification Other

If you have multiple income verification methods to list or do not see your type of income verification method listed, please enter the information in this 'Other' field.

Income Frequency

Income

Number only

GHC Patient?

Account Number

4.

Name

DOB

Relationship

Relationship Other

Income Verification Method

Income Verification Other

If you have multiple income verification methods to list or do not see your type of income verification method listed, please enter the information in this 'Other' field.

Income Frequency

Income

Number only

GHC Patient?

Account Number

5.

Name

DOB

Relationship

Relationship Other

Income Verification Method

Income Verification Other

If you have multiple income verification methods to list or do not see your type of income verification method listed, please enter the information in this 'Other' field.

Income Frequency

Income

Number only

GHC Patient?

Account Number

6.

Name

DOB

Relationship

Relationship Other

Income Verification Method

Income Verification Other

If you have multiple income verification methods to list or do not see your type of income verification method listed, please enter the information in this 'Other' field.

Income Frequency

Income

Number only

GHC Patient?

Account Number

7.

Name

DOB

Relationship

Relationship Other

Income Verification Method

Income Verification Other

If you have multiple income verification methods to list or do not see your type of income verification method listed, please enter the information in this 'Other' field.

Income Frequency

Income

Number only

GHC Patient?

Account Number

Total Annual Income:

Self-Attestation

Patient Financial Self-Attestation Agreement/Acknowledgement

Complete the “Patient Financial Self-Attestation Agreement/Acknowledgement” section of the application in full. Important Note: Select either “Accept” or “Decline” under this section. Please select only one.

I understand that Genesis Healthcare, Inc. will use the information that I have provided to determine my financial eligibility for federally subsidized health care. I further attest that the information that I have provided to Genesis Healthcare, Inc. is true and correct. I understand it is my responsibility to notify GHC of any changes to my income. I also understand that I must re-apply for the sliding fee program every 12 months, or sooner if my family household income changes.

To Accept, please select 'Accept':

I acknowledge that I have been provided information related to this Application and DECLINE to participate at this time.

To Decline, please select 'Decline':

Reason for Decline (if applicable):

Print Name

Patient Financial Self-Attestation Agreement/Acknowledgement

Relationship to Patient

Patient Financial Self-Attestation Agreement/Acknowledgement

Signature

Patient Financial Self-Attestation Agreement/Acknowledgement

​​GHC Sliding Fee Application