Sliding Fee Scale & Insurance

To Apply:
Fill out the application below, print on your computer's printer and mail to: North Woods Community Health Center, 600 Shell Creek Road, Minong, Wisconsin 54859. We will need proof of your income, either your current IRS 1040 Tax Return or your annual benefit notice from the Social Security Administration. Completed applications can also be dropped off at either of our clinics.

NOTE: Medicare, Medicaid and BadgerCare recipients are not eligible for the Sliding Fee Scale Program.

First Name of Head of Household:
Last Name:

Mailing Address:
City:
State: Zip:

Telephone:

Insurance: Blue Shield Medicare Medicaid
Healthsource Other:

Subscriber Name (On ID Card):
Group No.:
Effective Date:

Household Members:
Patient: Date of Birth:
Other: Date of Birth:
Child: Date of Birth:
Child: Date of Birth:
Child: Date of Birth:

Pregnant: Yes No
Due Date:

CURRENT ESTIMATE OF MONTHLY INCOME FOR ALL HOUSEHOLD MEMBERS:
Gross Income: Cash Welfare Payments:
Social Security, Pensions: Child Support:
Retirement Income: Alimony:
Business Income: Disability Income:
Unemployment Compensation: Interest:
Any Other Income: TOTAL INCOME:

To process your application, you must supply the following proof of income: A copy of your IRS 1040 and if on Social Security, a copy of your yearly benefit notice.
If you do not file taxes check here:

Special needs and circumstances which would help accurately reflect your current financial situation (i.e. other medical bills, etc.)

Employment Status/Household Members:
Employed By:
Address:
Previous Employer:
Address:

Are You Disabled?: Yes No
If Yes, what is your disability?:

This is to certify that the above information is true, and hereby authorize North Woods Community Health Center to verify any of the above data and release the above information to referring/mutual providers of care. (Sign and date below after printing this application form on your computer's printer).

Signature of Head of Household:

Date:

Updated 6/08