Confidential Financial Statement
Today’s Date:
Patient Name:
Address:
Date of Birth:
Phone Number:
Please complete the following statements as accurately and completely as possible. White House Clinics
reserves the right to withdraw discounts for failure to provide correct information. It is your responsibility to
inform us immediately of any change in income and/or insurance status.
White House Clinics is required by the Bureau of Primary Healthcare to obtain proof of income from patients
annually. We use the proof of income, along with the information gathered on this form, to determine the
amount we can discount the fees charged to you and your family. WE CANNOT PROVIDE A DISCOUNT
WITHOUT THIS INFORMATION. Today’s visit will be discounted based on the information provided below. If
you do not have documentation for today’s visit, you will be considered self-pay until verification of your
income is received [must be received by next visit or 30 days (whichever comes first)] and responsible for the
cost of all services provided. (Initial)
The information contained on this form is protected under HIPAA legislation. It will be used only for the
purposes of determining the level of discount provided and to enroll you in Pharmaceutical Patient Assistance
Programs. Your signature at the conclusion of this form indicates your consent for the sharing of this
information with necessary pharmaceutical companies.
Please list all members residing in your household (including patient).
Name
Date of Birth
Social Security #
1.
2.
3.
4.
5.
6.
Does the patient have any health insurance?
Does the patient have any dental insurance?
Do you have a prescription card?
Yes
Yes
Yes
No
No
No
How many members in the household work?

 
Does anyone in the household receive money from the following:
1. Wages from Employment
2. Self-Employment Wages
3. Social Security Checks
4. Disability Checks
5. Farming Income
6. SSI
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
10. Retirement
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
11. Black Lung
12. Alimony
13. Child Support
14. Military Wages
15. Unemployment
16. Rental Property
17. Worker’s Comp.
7. V.A. Pension
8. Interest Income
9. Food Stamps
If your household has no income, who pays your monthly bills?
In order to receive the Sliding Fee Discount at White House Clinics, you must return the White House Clinics’ Sliding Fee
Authorization form. Each member of your household (18 years of age and older) must sign the White House Clinics’
Sliding Fee Authorization form. This form will also be used to determine eligibility for Pharmaceutical Prescription
Assistance Programs. (Patient’s Initials)
Signature of Interviewer/WHC Employee
Date
FOR CLINIC USE ONLY (To Be Completed by Interviewer)
Income Source
Name
Amount on Document
Yearly Income
X
X
X
X
X
X
X
X
X
X
X
X
X
=
=
=
=
=
=
=
=
=
=
=
=
=
Total Yearly Income:
Expiration Date:
WHC-McKee_____
WHC-Paint Lick_____
Sliding Fee Level Approved:
Facility: BPCC_____ WHC-Berea_____
WHC-Mt. Vernon_____ WHC-Richmond_____
WHC-Irvine_____
Patient’s eligibility for Medicaid has been verified on the Kentucky Medicaid website: Yes No
Signed: ________________________________________ Date: __________________________________

 
White House Clinics’ Sliding Fee
Authorization Form
My signature below enrolls me in White House Clinics’ Sliding Fee Discount Program, so long as I provide all necessary
proof of income verification for all household members.
My signature authorizes White House Clinics to share my financial information with Pharmaceutical Prescription
Assistance Programs so that I may have access to those medications available from various drug companies.
Each member of your household (18 years of age and older) must sign and date the White House Clinics’ Sliding Fee
Authorization form.
Name
Name
Signature
Signature
Date
Date
Name
Name
Name
Name
Name
Signature
Signature
Signature
Signature
Signature
Date
Date
Date
Date
Date