Discount Fee Program Application

How do I become a patient?

¿Cómo me convierto en paciente?

The Community Health Center of the New River Valley is a non-profit healthcare organization that serves uninsured individuals, as well as people who are insured with Medicaid, Medicare, and private insurance. No one is ever turned away from Community Health Center due to an inability to pay.

Discount Fee Program Application

*The Discount Fee Program is only available to patients whose incomes fall at or below 200% of the Federal Poverty Line. You are required to provide ALL income that is received in your Household. Examples of Income include: Paystubs, Social Security Benefit Letter, SNAP/WIC Letter, Self-Employment, Retirement/Pension, Letter from Employer, and other documentation of income from any other source.

Telephone number where you can most often be reached, whether home or cellular.
Please list them below, with the required information for each.
(your name goes here; First, Last)
Social Security Number
Monthly Gross Income
(If employed)
Social Security Number
Monthly Gross Income
(If employed)
Social Security Number
Monthly Gross Income
(If employed)
Social Security Number
Monthly Gross Income
(If employed)
Social Security Number
Monthly Gross Income
(If employed)
*If someone can claim you as a dependent on their taxes, then list all other family members on that tax return. Document and provide proof of all income received: Paycheck stubs, Retirement, Social Security, Pension, Disability, Worker’s Compensation, Unemployment, Child Support, and ALL others not listed.

Application will be rejected if documentation is not provided.

Employer and Income Information

(month/year)

Unemployment and Disability Information

(month, year)

Government Assistance adn Insurance Information

Proof of income

In order to qualify for the Discount Fee Program, you are required to provide proof of identification and ALL income that has been received in your household. Examples of income include: Paycheck stubs for most recent full month of work, Social Security Letter, SNAP/WIC Benefits Letter, Self -Employment Documentation (Taxes are Recommended), Letter from Employer on Company Letterhead, Retirement/Pension, Documentation of income from any other source. Please upload proof of income below or email applications@chcnrv.org
Click or drag a file to this area to upload.
Click or drag a file to this area to upload.
Click or drag a file to this area to upload.
Click or drag a file to this area to upload.
Click or drag a file to this area to upload.
The information provided is, to the best of my knowledge and belief, accurate and true. I authorize the release of all information which the Community Health Center may need to determine whether I qualify for financial assistance through their Discount Fee Program. I understand that eligibility in the program expires 12 months from my signature date below and that I must reapply after the eligibility period expires. I understand that I must inform the Center of any changes in my household (income and size) during this 12-month period.