River Valley Health Sliding Fee Scale Form

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This field is for validation purposes and should be left unchanged.

To comply with Federal regulation, in order to give you a discount on our services, it is necessary for us to ask some person questions. Your answers will be held on file and in strict confidence. You must verify your income and household size at least once each year. In order to quality for discounts on services, you must show proof of income for all adults over the age of 18, living in the household, who financially contribute to the said household unit.

Name(Required)

First Last

Your Date of Birth(Required)

Household Size(Required)

Phone

List name(s) and birthdate(s) of all adults over the age of 18 living in the household who financially contribute to the said household unit and dependent children under 18 years of age living in the same household.

Household members names and birthdates

Name

Birthdate

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Todays Date(Required)

Please upload income documents here(Required)

Accepted file types: pdf, Max. file size: 16 MB.

Signature(Required)

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River Valley Health Sliding Fee Scale Form

River Valley Health Sliding Fee Scale Form

Seeking After-Hours Care?

If you require assistance outside of regular office hours, please call 570-567-5400 and press 0 to be connected to our after-hours nurse triage. Our dedicated team is here to provide support and guidance when you need it most. Your health and well-being are our priority, 24/7.