A reduction in fees according to income will be applied to all eligible patient services at NEPA Community Health Care. Eligibility will be determined from an application based on income for the past twelve (12) months. In cases of extreme or life-altering circumstances, the last three (3) month period will be considered.

Income includes, but is not limited to:

  • The full amount of gross income earned before taxes and deductions (demonstrated via two months’ pay stubs, W-2, etc.)
  • The net income earned from the operation of a business, i.e. total revenue minus business operating expenses
    • This also includes any withdrawals of cash from the business or profession for your personal use (demonstrated via tax return)
  • Monthly interest and dividend income credited to an applicant’s bank account and available for use
  • The monthly payment amount received from Social Security, annuities, gas leases, retirement funds, pensions, disability and other similar types of periodic payments
  • Any monthly payments in lieu of earnings, such as unemployment, disability compensation, SSI, SSDI and worker’s compensation
  • Monthly income from government agencies (excluding amounts designated for shelter and utilities), WIC, food stamps and childcare
  • Alimony, child support and foster care payments received from organizations or from persons not residing in the dwelling
  • All basic pay, special day and allowances of a member of the Armed Forces excluding special pay for exposure to hostile fire

Patients will be notified of the outcome of their application as well as the expected payment schedule within one (1) week of receipt of a complete application. Noncompliance with the payment schedule without communication from the patient will result in the forfeiture of any reduction, and normal collection procedures will ensue.

IMPORTANT 

Please fill this form out in its entirety and note that proof of income must accompany your application to be considered complete. To ensure patient confidentiality, this documentation cannot be submitted online. Please bring your proof of income to any NEPA Community Health Care location following submission of your application.

A Self-Declaration of Income (see separate form if needed) will remain valid for up to three (3) months of coverage.

  • Date Format: MM slash DD slash YYYY
  • Household MembersDate of BirthRelationship to Applicant