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Discount Fee Application & Agreement

Discount Fee Application & Agreement

Premier Community Healthcare Group, Inc. provides essential services regardless of the patient’s ability to pay.

Patient Information
Income Information

Proof of income is required. Acceptable documents include: pay stubs, tax return, SSI/SSDI letter, unemployment statement, or a signed self-declaration of no income.

Agreement & Signature

I certify that the information provided is true and accurate. I understand that Premier may verify this information. I agree to notify Premier if my financial situation changes.

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