b'Statement from Social Security stating earned income forcurrent yearSocial Security TPQY (Third Party Query System) form forcurrent yearW-2 FormsProof of unemployment benefitsThird Party Letter of Support form Self-Declaration of Income form In general, patients at or below 100% of the federal poverty level (FPL) will pay a nominal fee, which doesnt reflect the actual cost of the service. Individuals between 100% FPL and 200% FPL will get a discount. Anyone above 200% FPL will receive no discounts. Payment options are available if you cant pay your charges in full.Finally, health center may serve patients with third partyinsurance that does not cover or only partially covers fees forcertain health center services. In general, these patients are charged no more for any out-of-pocket costs that they would have paid under the applicable SFDS discount pay class.If you need more information, please call us at:305.576.1234Ext. 403 or 502To access the sliding fee determination worksheet online visit:careresource.org/patient-infoFor a list of federal, State of Florida, corporate, and community support, please view:careresource.org/our-supporters-39-'