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Alternative Income Declaration Form

Alternative Income Verification

Premier Community HealthCare Group, Inc. — If you are unable to provide check stubs, bank statements, or other income verification, please complete this form.

Patient Information
Option 1: Statement of Support

To be completed by the individual providing financial support to you and/or your dependents.

Option 2: Self-Declaration of Income

To be completed by the patient if no other income documentation is available.

Patient Signature

I certify that the information provided is true and accurate. I understand this verification is valid for one (1) year or sooner if my income situation changes.

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