Discount Program Application

It is necessary to ask you for personal financial information in order to give you a discount on your healthcare services provided by Northwest Health Services. This information will be held in our office in strict confidence. Discount Program applications will expire one year from the date you apply. At that time, we will ask you to again verify your current income and number of household members in order to receive discounts on your services.

Date/Time
Applicant Name:
Address
Date of Birth

Household Members

Household members must actually live in your household, regardless of marital status, and you must be financially responsible for them. Please list all household members' names and dates of birth (include yourself).

Would you like to add the first household member?
#1 Name
#1 Date of Birth
Would you like to add another household member?
#2 Name
#2 Date of Birth
Would you like to add another household member?
#3 Name
#3 Date of Birth
Would you like to add another household member?
#4 Name
#4 Date of Birth
Would you like to add another household member?
#5 Name
#5 Date of Birth
Would you like to add another household member?
#6 Name
#6 Date of Birth
Would you like to add another household member?
#7 Name
#7 Date of Birth
Would you like to add another household member?
#8 Name
#8 Date of Birth
Would you like to add another household member?
#9 Name
#9 Date of Birth

Household Income

Household income includes ALL income generated by the household, regardless of marital status. Income may include but it not limited to the following. Please mark all that apply to your household income and provide proof of all income marked below.

$
Types of income that apply to your household:
Would you like to upload a proof of income (pay stubs, w2 etc.)?
Upload Proof of Income #1
No File Chosen
File uploads may not work on some mobile devices.
Would you like to upload another proof of income (pay stubs, w2 etc.)?
Upload Proof of Income #2
No File Chosen
File uploads may not work on some mobile devices.
Would you like to upload another proof of income (pay stubs, w2 etc.)?
Upload Proof of Income #3
No File Chosen
File uploads may not work on some mobile devices.
Would you like to upload another proof of income (pay stubs, w2 etc.)?
Upload Proof of Income #4
No File Chosen
File uploads may not work on some mobile devices.

Signature

I understand:

  • If I have insurance I must show a copy of my current insurance card at each visit and my insurance must be filed and processed/paid before I receive any benefits from the Discount Program.
  • If I receive insurance payments I must bring the payment to the office to be applied to my visit before my discount will be given.
  • Services not eligible for discounts are:
    • Motor Vehicle Accidents
    • Workers Comp
    • Elective cosmetic procedures and hospital procedures
    • Services received from providers outside Northwest Health Services
  • I have read and understand the information contained in   “The Discount Program Details” and agree to abide by these guidelines.
  • I understand my information will be kept in strict confidence and that if my income changes I am required to notify NHS on my next visit to the clinic.  
  • I declare the information I have given is true and give Northwest Health Services (NHS) consent to investigate any information given in this application.  
  • Based on the number of people in my household and the income information I provided, I understand my copay will be discussed with me prior to services being rendered and this copay must be paid at the time of service. 
  • I further understand that copays for dental services vary, based on procedure, and the amount due from me will be discussed with me prior to services being rendered.
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