Online Sliding Scale Application – Southeast MS Rural Health

Online Sliding Scale Application

Comments
This field is for validation purposes and should be left unchanged.
Your application will automatically be emailed to the clinic you select in the drop-down menu.
Clinic Location*
Applicant's Name:*
First Middle Last
Date of Birth:*
MM slash DD slash YYYY

Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone #:*
Work Phone #:*
List your household members, include yourself, spouse, children, and any other individuals that live in your home:*
Name Date of Birth Employed? Yes or No Notes

Do you or any household member have or have applied for Medicaid, Medicare, Disability, Social Security, or any other Federally Funded Program?*
If yes, please list:
Name Insurance Coverage Name Policy Number

Proof of Income*
Please upload your proof of income by taking a picture on your mobile device or uploading documents from your computer.

Drop files here or

Max. file size: 2 MB.

Consent*
I certify that all of the information I have provided is true, accurate and complete to the best of my knowledge.
Signature of Applicant*
For SEMRHI Staff Only
SEMRHI Staff Signature 1
SEMRHI Staff Signature 2

Δ