Verification of Earnings

The following information is required for use in determining if services rendered by client are eligible to be covered through funding provided by the Indigent Health Care 1/2 cent sales surtax. Information will be used solely for this purpose. Eligibility determination for coverage under this funding does not approve or deny client to receive services at the facility. Please complete the below for any household member of the client needing verification of earnings (including client). 

Address Line 1
Address Line 2
City
State or Region
Country
Zip
Address Line 1
Address Line 2
City
State or Region
Country
Zip

Gross Earnings

Please enter your gross earnings in $USD for the selected date range.

Insurance Coverage

I certify that the information provided in this form is accurate and true.