Patient Application

 

Click here for the Sliding Fee Discount Patient Application

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Patient Information

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It is the policy of Randolph Health Medical Group to provide essential services regardless of the patient’s ability to pay. Discounts are offered based on the family size and annual income. Please speak with the front desk staff at this office, contact Patient Account Staff, 336-625-6072 x1027, or click here to obtain an application to see if you and/or your family are eligible for a discount.

The discount will apply to all services received at this clinic except:  
 

• Services or equipment that are purchased from outside

• Reference lab testing

• Drugs

• Durable medical equipment

• X-ray interpretation by a consulting radiologist, and other such services

• Any elective care (other than recommended preventative care)

Requests for discounted services may be made by patients, family members, social services staff or others who are aware of existing financial hardship.
The Sliding Fee Discount Program will only be made available for clinic visits.

Information about the Sliding Fee Discount Program policy and procedure will be provided and assistance offered for completion of the application. Dignity and confidentiality will be respected for all who seek and/or are provided charitable services.

ELIGIBILITY REQUIREMENTS:
 

• All alternative payment resources must be exhausted, including all third-party payment from insurance(s), Federal and State programs.

• Complete Sliding Fee Discount Program application in its entirety. This form must be completed every 12 months or if your financial situation changes.

• At or above the poverty level based on income and family size.

QUALIFICATIONS:

Income Verification

Applicants must provide one of the following:
 

• Prior year W-2

• 3 most recent pay stubs

• Letter from employer

• Form 4506-T (if W-2 not filed)

Self-employed individuals will be required to submit detail of the most recent three months of income and expenses for the business.  

Adequate information must be made available to determine eligibility for the program. Self-declaration of Income may only be used in special circumstances. Specific examples include participants who are homeless. Patients who are unable to provide written verification must provide a signed statement of income, and why (s)he is unable to provide independent verification. This statement will be presented to RHMG Director of Patient Accounts or designee for review and final determination as to the sliding fee percentage. Self-declared patients will be responsible for 100% of their charges until management determines the appropriate category.

Patients approved for Sliding Fee Discount will pay a nominal fee at each visit based on their eligibility.

If a patient verbally expresses an unwillingness to pay or vacates the premises without paying for services, the patient will be contacted in writing regarding their payment obligations. If the patient does not make effort to pay or fails to respond within 60 days, this constitutes refusal to pay. At this point in time, RHMG can explore options not limited, but including referring the account to outside collections.