Discount Fee Program Application

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.

Application Form

*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.
(include yourself)
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 information

(month/year)

Income Information

Unemployment information

Disability Information

Government Assistance Information

Insurance Information

Personal Information

Proof of income

In order to qualify for the Discount Free Program, we are required to obtain several pieces of information to accurately verify the need to funding entities. You may be asked to provide additional information.
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.