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Income Policy for New Patients
You must bring ONE verification form from each categories each Year
if you wish to receive the patient discount.
1. Proof of family Income
a.
Last year's 1040 or 1040(a) tax return.
b.
Last year's W-2 or 1099
c.
Recent check stubs wlin the last 30 days (with year to date)
d.
Unemployment letter (from State Employment Agency)
2. Proof of Identification
a.
Drivers license w/photo or valid state ill
b.
Alien Registration Card
c.
Passport
d.
Work/School Identification w/photo
e.
Birth Certificate
3. Proof of Dependents (Each)
a.
Birth Certificate
b.
Social Security Card
c.
Child ID (School)
d.
Medicaid Card
4. Proof of Address
a.
Utility Bill (with your name on it)
b.
Piece of mail with recent postmark (w/in the last 30 days)
c.
Current lease agreement listing all persons in the household.
5. Proof of Insurance
a.
Private Insurance card
b.
Medicaid card
c.
Medicare card
Please note that if you are unable to bring income verification with you or within 30 days of service, you will NOT RECEIVE A DISCOUNT FOR SERVICES RENDERED TODAY. This means that Without all the verification listed above you must PAY FULL PRICE for the services you receive until you bring the information to verify your income and household.
Prior to receiving health care services at Samuel U Rodgers Health Center (SURCHC), a minimum Payment is required. The minimum payment will range from $10.00 to $40.00
The minimum payment will be deducted from any charge you incur during your visit on the day of payment. All remaining balances will be due prior to leaving the center.
If any of the information is unclear, please feel free to ask the Customer
Service Representative assisting you.