Online Sliding Scale Application – Southeast MS Rural Health

Online Sliding Scale Application

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:*
Date Format: 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 If over 18 years of age, employed? Yes or No Social Security # Relationship

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

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*
Name
This field is for validation purposes and should be left unchanged.