Sliding Scale Application

Below, you will find different sets of sliding scale applications. Although the actual application is the same, the requirements and attachments for each category is different. Please choose the one that best describes your situation. Please be advised that an incomplete application or failure to submit the required documents will result in the immediate denial of your application.

Employed

Currently employed sliding scale applicants must submit the application as well as the following forms to be considered for the Sliding Fee Scale Discount.

Sliding Fee Scale Application Form – please fill out this form fully and as accurately as possible.
Sliding Fee Scale Employment Verification Form – the employment verification form must be filled out entirely.

Self Employed

Self-employed sliding scale applicants must submit the application as well as the following forms to be considered for the Sliding Fee Scale Discount and submit the required documentation as well.

Sliding Fee Scale Application Form – please fill out this form fully and as accurately as possible.
Proof Of Income – such as Income Tax Return or any other type of document that shows your earning must be attached in the application.

The Application and all Proof Of Income can either be faxed to us at (573) 332-7998, or it can be emailed to us at capefamilymedicalclinic@gmail.com or you may submit it to us directly at the clinic.

Unemployed

Unemployed sliding scale applicants must submit the application as well as the following forms to be considered for the Sliding Fee Scale Discount and submit the required documentation as well.

Sliding Fee Scale Application Form – please fill out this form fully and as accurately as possible.
Circumstance Verification Form – unemployed applicants must submit two (2) Circumstance Verification Forms from two (2) different individuals not living in the same home as you who can verify your current financial situation.
Monthly Expense Verification Form – unemployed applicants must submit this form explaining their expenses and how they currently pay any bills or misc. expenses.

The Application, the two Circumstance Verification Forms and the Monthly Expense Verification Form can either be faxed to us at (573) 332-7998, or it can be emailed to us at capefamilymedicalclinic@gmail.com or you may submit it to us directly at the clinic.

* This practice services all patients regardless of the ability to pay. Discounts for essential services are offered based on family size and income.
** To view the actual sliding scale, you can do so by clicking here.

Sliding Scale Application

Employed

Self Employed

Unemployed

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