Healthcare Income Attestation

HEALTHCARE INCOME ATTESTATION

Patient Information

Insurance Information

Household & Income Details

Provide information for all persons who reside in the household and whose income is considered for eligibility determinations. Attach documentation to support amounts claimed below.

Primary sources of income (check all that apply):

Employment    Self-employment    Unemployment    Public assistance    SSI/SSD    Child support    Other

Documentation Checklist

I have provided or will provide the following documentation to substantiate income reported (check all that apply):

Most recent pay stubs (last 30 days)
Benefit/award letters (Social Security, TANF, SNAP, etc.)
Federal/state tax returns (most recent)
Bank statements (most recent 2 months)
Other supporting documents

Certification, Consent, and Authorization

I, the undersigned, certify under penalty of perjury that the information provided in this Healthcare Income Attestation is true, complete, and accurate to the best of my knowledge. I understand that intentionally providing false information or withholding material information may result in denial, termination, recoupment of benefits, or other civil or criminal penalties under applicable law.

I authorize the medical provider and authorized representatives to verify earnings, benefits, and other sources of income with employers, agencies, financial institutions, and other third parties for the purpose of determining eligibility for medically related financial assistance or sliding scale fees. This authorization remains in effect until the expiration date indicated below or until revoked in writing.

Consent to verify income and benefits: I consent to verification of income and benefits as described above.

Notice of Privacy Practices and HIPAA Acknowledgment: I acknowledge receipt of the provider's privacy practices and understand how my information may be used and disclosed for verification of financial eligibility.

By signing below I certify that I have reviewed this attestation and the supporting documentation, that the information is accurate and complete, and that I authorize the verification described herein. I understand I may withdraw this authorization in writing at any time, but such withdrawal will not affect any actions taken prior to the receipt of the written revocation.

Sign Now