Verification of Income -Spanish

VERIFICACIÓN DOCUMENTADOS DE INGRESOS /
Fecha__________
TAMAÑO DE LA FAMILIA
(Attach copies of proof of income, such as paycheck stubs, income tax returns, etc.)
Always make copies, never hand over originals you may need for use later.
INGRESOS
TAMAÑO DEL HOGAR
UNA MUJER EMBARAZADA CONTARÁ COMO DOS EN EL HOGAR
COSTO CORREDERA
Yo certifico que la información que he dado es correcta, a lo
mejor de mi conocimiento. Entiendo que voy a ser responsable
de las consecuencias (por ejemplo, pagos, multas, acciones
legales, etc.) resultantes de información falsa.
Firma del paciente
Fecha
WHITESIDE COUNTY COMMUNITY HEALTH CLINIC 2014
TAMAÑO
DE
FAMILIA
100% descuento
Paga $25*
80% de descuento
Paga 20%
60% de descuento
Paga 40%
40% de descuento
Paga 60%
20% de descuento
Paga 80%
0% descuento
Paga 100%
1
$0-11,670
$11,67114,588
$14,58917,505
$17,50620,423
$20,42423,340
$23,341
2
$0-15,730
$15,73119,663
$19,66423,595
$23,59627,528
$27,52931,460
$31,461
3
$0-19,790
$19,79124,738
$24,73929,685
$29,68634,633
$34,63439,580
$39,581
4
$0-23,850
$23,85129,813
$29,81435,775
$35,77641,738
$41,73947,700
$47,701
5
$0-27,910
$27,91134,888
$34,889 41,865
$41,86648,843
$48,84455,820
$55,821
6
$0-31,970
$31,97139,963
$39,96447,955
$47,95655,948
$55,94963,940
$63,941
7
$0-36,030
$36,03145,038
$45,03954,045
$54,04663,053
$63,05472,060
$72,061
8
$0-40,090
$40,09150,113
$50,11460,135
$60,13670,158
$70,15980,180
$80,181
Por cada
miembro
adicional de
la familia
+$4,060
CHC
Población
objetivo
a 100% de la
pobreza
a 125% de la
pobreza
a 150% de la
pobreza
a 175% de la
pobreza
a 200% de la
pobreza
*Mínimo $ 25, Médico, Dental y Salud Mental
Firma del entrevistador (Interviewer’s Signature)
CHC Forms – Documented Verification of Income Family Size – Spanish - 2014
200% de la
pobreza
PROOF OF INCOME WORKSHEET
Patient name ___________________________________
If they get paid biweekly take gross amount add it
together, total amount divided by 2 then times 26.
Number of people in household____________________
Total amount _________________
Enter gross amount _________________
_________________
Amount divided by 2 ____________
Amount times 26 ______________
This amount is your yearly income
_________________
_________________
If they get paid weekly take gross amount add it together,
total amount divided by 4 then times 52.
If they get paid bimonthly take gross amount add it
together, total amount divided by 2 then times 24.
Total amount _________________
Total amount _________________
Amount divided by 4 ____________
Amount divided by 2 ____________
Amount times 52 ______________
This amount is your yearly income
Amount times 24 ______________
This amount is your yearly income
Completed By________________________ Date______________________________
DISCOUNT SLIDING SCALE FEES ELIGIBILITY CRITERIA
The Whiteside County Community Health Clinic is a federally qualified health center that provides
primary and preventative health care services to individuals who have limited access to health care due to
the lack of financial resources or health insurance. To ensure that income or lack of insurance is not a
barrier to care, low-income patients who are not covered by public or private insurance are charged on a
sliding fee scale.
1. The Clinic uses the Federal Poverty Income level guidelines to determine the discount the patient
will receive based on their income and family size.
2. If a patient wishes to be evaluated for the Clinic’s sliding fee scale, they MUST bring information
regarding their house hold income with them when they come to their initial appointment. Patient
will be charged full fee until proof of income is provided. Patient will be charged full fee until
proof of income is provided.
3. To continue to qualify for sliding fees, the patient will need to bring income information once a
year.
ACCEPTABLE FORMS OF PROOF OF INCOME:
See the “Income Verification for Sliding Fee Discounts” policy and the “Protocol for Income Calculation
for Documented Verification of Income/Family Size Form.”
CHC Forms – Documented Verification of Income Family Size – Spanish - 2014