Discount Application

Discount Application
At Primary Health Solutions our Discount Program allows us to reduce the fees for you or your family's care here at PHS. You may apply for the program to see if you qualify for a discount. Both Insured and Uninsured patients may qualify!

Discount Application
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Applicant Name (if not patient)

First NameLast Name
Applicant Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please list yourself and all other members of the household and their income, if applicable.

Household = people you support financially or who support you financially.
- Children include biological, adopted, stepchildren, or children you care for as a legal guardian
- If children live in two homes, list them only in the household that is responsible for their medical bills.
If you're including extended family as part of your household for assistance, you may need to provide extra documents—like your tax return showing them as dependents or proving you're the head of household.

Household income is all gross income for any household members listed.

Gross income is the total amount before any deductions or taxes are taken out.
By selecting this box, I am choosing not to fill out the Discount Application at this time. I understand that I am giving up my right to any discount I might qualify for and that I am responsible for paying the full cost of my care at the time of service.
Household Income Information - Select + Add Row to add more names
Please upload your proof of income.

Cancelof
If you are unable to provide proof of income, please indicate why:
How often are you paid?
How much money do you receive when you are paid?
I certify that I have no other way to document my income and that all the above information is true and correct. I understand that this information is used to determine eligibility for the Discount Program at Primary Health Solutions. This documentation will become a part of my medical record.
I understand that:
- I must submit documents to verify my financial situation.
- These documents are due within 30 days or before my next visit, whichever comes first.
- I need to report any changes in my situation.
- I must complete a new Discount Application at least once every 12 months.
Signature of Patient or Responsible Party
Patients whose insurance provides no payment due to deductible obligations will be charged using the same methodology as self-pay patients. The pharmacy will not dispense medications below its established minimum cost recovery amount.
Should be Empty: