I hereby request Tioga Medical Center make a written determination of my eligibility for uncompensated services at Tioga Medical Center. I understand the information which I submit concerning my annual income and family size is subject to verification by Tioga Medical Center. I also understand that if the information which I submit is determined to be false, such a determination will result in denial of providing services as uncompensated services, and that I will be liable for charges for services provided.
a. A written release or oral verification of wage information from your employer. b. Pay stubs showing monthly or yearly earnings. c. Oral verification from public welfare agencies. d. Unemployment Compensation or Worker’s Compensation benefit forms. e. W-2 withholding forms. f. Income tax returns from prior year, or complete a Form 4506-T to verify you did not file Federal Income tax.
I affirm that the above information is true and correct to the best of my knowledge. Initial here as your electronic signature:
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