Finding Number: 2022-001 Assistance Listing Numbers: 93.224, 93.527 Cluster/Program Name: Health Center Program Cluster [including COVID-19 funds] Federal Agency: U.S. Department of Health and Human Services Federal Award Identification Numbers: Various Federal Award Years in Cluster: Various grant periods: February 1, 2019-January 31, 2020; February 1, 2021-January 31, 2022; February 1, 2022 to January 31, 2023; April 1, 2020 to March 31, 2021; April 1, 2021 to March 31, 2023 Finding Type: Significant Deficiency Compliance Requirement: Special Tests and Provisions Pass-Through Entity: None Questioned Costs: $0 ChesPenn Health Services, Inc. did not maintain complete patient files for all patients who received healthcare under the sliding fee arrangement. Condition and Context 4 out of 40 selected patients receiving healthcare under the sliding fee arrangement application had incomplete documentation of supervisory review. The sample was not a statistically valid sample. Criteria Under the compliance requirements listed in the Office of Management and Budget (?OMB?) Compliance Supplement for the Health Center Program Cluster, health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted based on the patient?s ability to pay. Cause As a result of the COVID-19 pandemic, controls that have historically been in place over maintaining patient files in the office were not followed in all instances. Historical controls were not followed based on COVID-19 epidemic staffing shortages and constraints and provision of virtual services. As a result, there were some incomplete applications due to human error. Effect or Potential Effect For 4 out of 40 patients selected for testing, the internal control procedure to perform additional supervisory check of the sliding fee discount application was not formally documented. This was considered a deficiency in internal controls. Recommendation We recommend that ChesPenn Health Services, Inc. continue to work towards implementing procedures established in the prior year as part of the corrective action plan for prior year finding. ChesPenn Health Services, Inc. should ensure new procedures cause all patient files to be maintained and to be completed fully. Views of Responsible Officials ChesPenn Health Services, Inc. will continue to monitor the process of maintaining paper copies of all sliding fee scale patient files in each office as a back-up to potential electronic system failures for scanning patient's records. In addition, ChesPenn Health Services, Inc.'s Compliance Officer and Chief Operating Officer will conduct random monthly audits of sliding fee applications at all three locations. Results from the audits will be presented to the site Office Manager who will then conduct staff training sessions with the Patient Service Representatives. The audit and subsequent training will include a review of the following parameters for proper documentation and sliding fee scale determination: Identification: o State issued driver's license o State issued or state recognized identification card o School identification o Government issued passport o If married, a copy of spouse's identification as well Social Security Cards: o For the applicant o For the spouse, if married o For all dependents 18 years of age or younger o For a college student, up to 23 years of age with college documentation o If a social security card is not available for a child, a birth certificate will be accepted Paystubs: o One recent pay stub, if married a copy from spouse as well o Benefits statement from social security, if married from husband and wife o Awards letter for unemployment, if married from husband and wife o Self-employed - Last year's income tax statement o If paid in cash, a letter from the employer, on company letter head that states the hourly rate and hours worked o If the letter is handwritten, the letter must be notarized o When an individual has no source of income and has no insurance, they are required to fill out the information on the front and the back of the sliding fee scale form. Photo identification and social security cards are required
Finding Number: 2022-001 Assistance Listing Numbers: 93.224, 93.527 Cluster/Program Name: Health Center Program Cluster [including COVID-19 funds] Federal Agency: U.S. Department of Health and Human Services Federal Award Identification Numbers: Various Federal Award Years in Cluster: Various grant periods: February 1, 2019-January 31, 2020; February 1, 2021-January 31, 2022; February 1, 2022 to January 31, 2023; April 1, 2020 to March 31, 2021; April 1, 2021 to March 31, 2023 Finding Type: Significant Deficiency Compliance Requirement: Special Tests and Provisions Pass-Through Entity: None Questioned Costs: $0 ChesPenn Health Services, Inc. did not maintain complete patient files for all patients who received healthcare under the sliding fee arrangement. Condition and Context 4 out of 40 selected patients receiving healthcare under the sliding fee arrangement application had incomplete documentation of supervisory review. The sample was not a statistically valid sample. Criteria Under the compliance requirements listed in the Office of Management and Budget (?OMB?) Compliance Supplement for the Health Center Program Cluster, health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted based on the patient?s ability to pay. Cause As a result of the COVID-19 pandemic, controls that have historically been in place over maintaining patient files in the office were not followed in all instances. Historical controls were not followed based on COVID-19 epidemic staffing shortages and constraints and provision of virtual services. As a result, there were some incomplete applications due to human error. Effect or Potential Effect For 4 out of 40 patients selected for testing, the internal control procedure to perform additional supervisory check of the sliding fee discount application was not formally documented. This was considered a deficiency in internal controls. Recommendation We recommend that ChesPenn Health Services, Inc. continue to work towards implementing procedures established in the prior year as part of the corrective action plan for prior year finding. ChesPenn Health Services, Inc. should ensure new procedures cause all patient files to be maintained and to be completed fully. Views of Responsible Officials ChesPenn Health Services, Inc. will continue to monitor the process of maintaining paper copies of all sliding fee scale patient files in each office as a back-up to potential electronic system failures for scanning patient's records. In addition, ChesPenn Health Services, Inc.'s Compliance Officer and Chief Operating Officer will conduct random monthly audits of sliding fee applications at all three locations. Results from the audits will be presented to the site Office Manager who will then conduct staff training sessions with the Patient Service Representatives. The audit and subsequent training will include a review of the following parameters for proper documentation and sliding fee scale determination: Identification: o State issued driver's license o State issued or state recognized identification card o School identification o Government issued passport o If married, a copy of spouse's identification as well Social Security Cards: o For the applicant o For the spouse, if married o For all dependents 18 years of age or younger o For a college student, up to 23 years of age with college documentation o If a social security card is not available for a child, a birth certificate will be accepted Paystubs: o One recent pay stub, if married a copy from spouse as well o Benefits statement from social security, if married from husband and wife o Awards letter for unemployment, if married from husband and wife o Self-employed - Last year's income tax statement o If paid in cash, a letter from the employer, on company letter head that states the hourly rate and hours worked o If the letter is handwritten, the letter must be notarized o When an individual has no source of income and has no insurance, they are required to fill out the information on the front and the back of the sliding fee scale form. Photo identification and social security cards are required
Finding Number: 2022-001 Assistance Listing Numbers: 93.224, 93.527 Cluster/Program Name: Health Center Program Cluster [including COVID-19 funds] Federal Agency: U.S. Department of Health and Human Services Federal Award Identification Numbers: Various Federal Award Years in Cluster: Various grant periods: February 1, 2019-January 31, 2020; February 1, 2021-January 31, 2022; February 1, 2022 to January 31, 2023; April 1, 2020 to March 31, 2021; April 1, 2021 to March 31, 2023 Finding Type: Significant Deficiency Compliance Requirement: Special Tests and Provisions Pass-Through Entity: None Questioned Costs: $0 ChesPenn Health Services, Inc. did not maintain complete patient files for all patients who received healthcare under the sliding fee arrangement. Condition and Context 4 out of 40 selected patients receiving healthcare under the sliding fee arrangement application had incomplete documentation of supervisory review. The sample was not a statistically valid sample. Criteria Under the compliance requirements listed in the Office of Management and Budget (?OMB?) Compliance Supplement for the Health Center Program Cluster, health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted based on the patient?s ability to pay. Cause As a result of the COVID-19 pandemic, controls that have historically been in place over maintaining patient files in the office were not followed in all instances. Historical controls were not followed based on COVID-19 epidemic staffing shortages and constraints and provision of virtual services. As a result, there were some incomplete applications due to human error. Effect or Potential Effect For 4 out of 40 patients selected for testing, the internal control procedure to perform additional supervisory check of the sliding fee discount application was not formally documented. This was considered a deficiency in internal controls. Recommendation We recommend that ChesPenn Health Services, Inc. continue to work towards implementing procedures established in the prior year as part of the corrective action plan for prior year finding. ChesPenn Health Services, Inc. should ensure new procedures cause all patient files to be maintained and to be completed fully. Views of Responsible Officials ChesPenn Health Services, Inc. will continue to monitor the process of maintaining paper copies of all sliding fee scale patient files in each office as a back-up to potential electronic system failures for scanning patient's records. In addition, ChesPenn Health Services, Inc.'s Compliance Officer and Chief Operating Officer will conduct random monthly audits of sliding fee applications at all three locations. Results from the audits will be presented to the site Office Manager who will then conduct staff training sessions with the Patient Service Representatives. The audit and subsequent training will include a review of the following parameters for proper documentation and sliding fee scale determination: Identification: o State issued driver's license o State issued or state recognized identification card o School identification o Government issued passport o If married, a copy of spouse's identification as well Social Security Cards: o For the applicant o For the spouse, if married o For all dependents 18 years of age or younger o For a college student, up to 23 years of age with college documentation o If a social security card is not available for a child, a birth certificate will be accepted Paystubs: o One recent pay stub, if married a copy from spouse as well o Benefits statement from social security, if married from husband and wife o Awards letter for unemployment, if married from husband and wife o Self-employed - Last year's income tax statement o If paid in cash, a letter from the employer, on company letter head that states the hourly rate and hours worked o If the letter is handwritten, the letter must be notarized o When an individual has no source of income and has no insurance, they are required to fill out the information on the front and the back of the sliding fee scale form. Photo identification and social security cards are required
Finding Number: 2022-001 Assistance Listing Numbers: 93.224, 93.527 Cluster/Program Name: Health Center Program Cluster [including COVID-19 funds] Federal Agency: U.S. Department of Health and Human Services Federal Award Identification Numbers: Various Federal Award Years in Cluster: Various grant periods: February 1, 2019-January 31, 2020; February 1, 2021-January 31, 2022; February 1, 2022 to January 31, 2023; April 1, 2020 to March 31, 2021; April 1, 2021 to March 31, 2023 Finding Type: Significant Deficiency Compliance Requirement: Special Tests and Provisions Pass-Through Entity: None Questioned Costs: $0 ChesPenn Health Services, Inc. did not maintain complete patient files for all patients who received healthcare under the sliding fee arrangement. Condition and Context 4 out of 40 selected patients receiving healthcare under the sliding fee arrangement application had incomplete documentation of supervisory review. The sample was not a statistically valid sample. Criteria Under the compliance requirements listed in the Office of Management and Budget (?OMB?) Compliance Supplement for the Health Center Program Cluster, health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted based on the patient?s ability to pay. Cause As a result of the COVID-19 pandemic, controls that have historically been in place over maintaining patient files in the office were not followed in all instances. Historical controls were not followed based on COVID-19 epidemic staffing shortages and constraints and provision of virtual services. As a result, there were some incomplete applications due to human error. Effect or Potential Effect For 4 out of 40 patients selected for testing, the internal control procedure to perform additional supervisory check of the sliding fee discount application was not formally documented. This was considered a deficiency in internal controls. Recommendation We recommend that ChesPenn Health Services, Inc. continue to work towards implementing procedures established in the prior year as part of the corrective action plan for prior year finding. ChesPenn Health Services, Inc. should ensure new procedures cause all patient files to be maintained and to be completed fully. Views of Responsible Officials ChesPenn Health Services, Inc. will continue to monitor the process of maintaining paper copies of all sliding fee scale patient files in each office as a back-up to potential electronic system failures for scanning patient's records. In addition, ChesPenn Health Services, Inc.'s Compliance Officer and Chief Operating Officer will conduct random monthly audits of sliding fee applications at all three locations. Results from the audits will be presented to the site Office Manager who will then conduct staff training sessions with the Patient Service Representatives. The audit and subsequent training will include a review of the following parameters for proper documentation and sliding fee scale determination: Identification: o State issued driver's license o State issued or state recognized identification card o School identification o Government issued passport o If married, a copy of spouse's identification as well Social Security Cards: o For the applicant o For the spouse, if married o For all dependents 18 years of age or younger o For a college student, up to 23 years of age with college documentation o If a social security card is not available for a child, a birth certificate will be accepted Paystubs: o One recent pay stub, if married a copy from spouse as well o Benefits statement from social security, if married from husband and wife o Awards letter for unemployment, if married from husband and wife o Self-employed - Last year's income tax statement o If paid in cash, a letter from the employer, on company letter head that states the hourly rate and hours worked o If the letter is handwritten, the letter must be notarized o When an individual has no source of income and has no insurance, they are required to fill out the information on the front and the back of the sliding fee scale form. Photo identification and social security cards are required
Finding Number: 2022-001 Assistance Listing Numbers: 93.224, 93.527 Cluster/Program Name: Health Center Program Cluster [including COVID-19 funds] Federal Agency: U.S. Department of Health and Human Services Federal Award Identification Numbers: Various Federal Award Years in Cluster: Various grant periods: February 1, 2019-January 31, 2020; February 1, 2021-January 31, 2022; February 1, 2022 to January 31, 2023; April 1, 2020 to March 31, 2021; April 1, 2021 to March 31, 2023 Finding Type: Significant Deficiency Compliance Requirement: Special Tests and Provisions Pass-Through Entity: None Questioned Costs: $0 ChesPenn Health Services, Inc. did not maintain complete patient files for all patients who received healthcare under the sliding fee arrangement. Condition and Context 4 out of 40 selected patients receiving healthcare under the sliding fee arrangement application had incomplete documentation of supervisory review. The sample was not a statistically valid sample. Criteria Under the compliance requirements listed in the Office of Management and Budget (?OMB?) Compliance Supplement for the Health Center Program Cluster, health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted based on the patient?s ability to pay. Cause As a result of the COVID-19 pandemic, controls that have historically been in place over maintaining patient files in the office were not followed in all instances. Historical controls were not followed based on COVID-19 epidemic staffing shortages and constraints and provision of virtual services. As a result, there were some incomplete applications due to human error. Effect or Potential Effect For 4 out of 40 patients selected for testing, the internal control procedure to perform additional supervisory check of the sliding fee discount application was not formally documented. This was considered a deficiency in internal controls. Recommendation We recommend that ChesPenn Health Services, Inc. continue to work towards implementing procedures established in the prior year as part of the corrective action plan for prior year finding. ChesPenn Health Services, Inc. should ensure new procedures cause all patient files to be maintained and to be completed fully. Views of Responsible Officials ChesPenn Health Services, Inc. will continue to monitor the process of maintaining paper copies of all sliding fee scale patient files in each office as a back-up to potential electronic system failures for scanning patient's records. In addition, ChesPenn Health Services, Inc.'s Compliance Officer and Chief Operating Officer will conduct random monthly audits of sliding fee applications at all three locations. Results from the audits will be presented to the site Office Manager who will then conduct staff training sessions with the Patient Service Representatives. The audit and subsequent training will include a review of the following parameters for proper documentation and sliding fee scale determination: Identification: o State issued driver's license o State issued or state recognized identification card o School identification o Government issued passport o If married, a copy of spouse's identification as well Social Security Cards: o For the applicant o For the spouse, if married o For all dependents 18 years of age or younger o For a college student, up to 23 years of age with college documentation o If a social security card is not available for a child, a birth certificate will be accepted Paystubs: o One recent pay stub, if married a copy from spouse as well o Benefits statement from social security, if married from husband and wife o Awards letter for unemployment, if married from husband and wife o Self-employed - Last year's income tax statement o If paid in cash, a letter from the employer, on company letter head that states the hourly rate and hours worked o If the letter is handwritten, the letter must be notarized o When an individual has no source of income and has no insurance, they are required to fill out the information on the front and the back of the sliding fee scale form. Photo identification and social security cards are required
Finding Number: 2022-001 Assistance Listing Numbers: 93.224, 93.527 Cluster/Program Name: Health Center Program Cluster [including COVID-19 funds] Federal Agency: U.S. Department of Health and Human Services Federal Award Identification Numbers: Various Federal Award Years in Cluster: Various grant periods: February 1, 2019-January 31, 2020; February 1, 2021-January 31, 2022; February 1, 2022 to January 31, 2023; April 1, 2020 to March 31, 2021; April 1, 2021 to March 31, 2023 Finding Type: Significant Deficiency Compliance Requirement: Special Tests and Provisions Pass-Through Entity: None Questioned Costs: $0 ChesPenn Health Services, Inc. did not maintain complete patient files for all patients who received healthcare under the sliding fee arrangement. Condition and Context 4 out of 40 selected patients receiving healthcare under the sliding fee arrangement application had incomplete documentation of supervisory review. The sample was not a statistically valid sample. Criteria Under the compliance requirements listed in the Office of Management and Budget (?OMB?) Compliance Supplement for the Health Center Program Cluster, health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted based on the patient?s ability to pay. Cause As a result of the COVID-19 pandemic, controls that have historically been in place over maintaining patient files in the office were not followed in all instances. Historical controls were not followed based on COVID-19 epidemic staffing shortages and constraints and provision of virtual services. As a result, there were some incomplete applications due to human error. Effect or Potential Effect For 4 out of 40 patients selected for testing, the internal control procedure to perform additional supervisory check of the sliding fee discount application was not formally documented. This was considered a deficiency in internal controls. Recommendation We recommend that ChesPenn Health Services, Inc. continue to work towards implementing procedures established in the prior year as part of the corrective action plan for prior year finding. ChesPenn Health Services, Inc. should ensure new procedures cause all patient files to be maintained and to be completed fully. Views of Responsible Officials ChesPenn Health Services, Inc. will continue to monitor the process of maintaining paper copies of all sliding fee scale patient files in each office as a back-up to potential electronic system failures for scanning patient's records. In addition, ChesPenn Health Services, Inc.'s Compliance Officer and Chief Operating Officer will conduct random monthly audits of sliding fee applications at all three locations. Results from the audits will be presented to the site Office Manager who will then conduct staff training sessions with the Patient Service Representatives. The audit and subsequent training will include a review of the following parameters for proper documentation and sliding fee scale determination: Identification: o State issued driver's license o State issued or state recognized identification card o School identification o Government issued passport o If married, a copy of spouse's identification as well Social Security Cards: o For the applicant o For the spouse, if married o For all dependents 18 years of age or younger o For a college student, up to 23 years of age with college documentation o If a social security card is not available for a child, a birth certificate will be accepted Paystubs: o One recent pay stub, if married a copy from spouse as well o Benefits statement from social security, if married from husband and wife o Awards letter for unemployment, if married from husband and wife o Self-employed - Last year's income tax statement o If paid in cash, a letter from the employer, on company letter head that states the hourly rate and hours worked o If the letter is handwritten, the letter must be notarized o When an individual has no source of income and has no insurance, they are required to fill out the information on the front and the back of the sliding fee scale form. Photo identification and social security cards are required
Finding Number: 2022-001 Assistance Listing Numbers: 93.224, 93.527 Cluster/Program Name: Health Center Program Cluster [including COVID-19 funds] Federal Agency: U.S. Department of Health and Human Services Federal Award Identification Numbers: Various Federal Award Years in Cluster: Various grant periods: February 1, 2019-January 31, 2020; February 1, 2021-January 31, 2022; February 1, 2022 to January 31, 2023; April 1, 2020 to March 31, 2021; April 1, 2021 to March 31, 2023 Finding Type: Significant Deficiency Compliance Requirement: Special Tests and Provisions Pass-Through Entity: None Questioned Costs: $0 ChesPenn Health Services, Inc. did not maintain complete patient files for all patients who received healthcare under the sliding fee arrangement. Condition and Context 4 out of 40 selected patients receiving healthcare under the sliding fee arrangement application had incomplete documentation of supervisory review. The sample was not a statistically valid sample. Criteria Under the compliance requirements listed in the Office of Management and Budget (?OMB?) Compliance Supplement for the Health Center Program Cluster, health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted based on the patient?s ability to pay. Cause As a result of the COVID-19 pandemic, controls that have historically been in place over maintaining patient files in the office were not followed in all instances. Historical controls were not followed based on COVID-19 epidemic staffing shortages and constraints and provision of virtual services. As a result, there were some incomplete applications due to human error. Effect or Potential Effect For 4 out of 40 patients selected for testing, the internal control procedure to perform additional supervisory check of the sliding fee discount application was not formally documented. This was considered a deficiency in internal controls. Recommendation We recommend that ChesPenn Health Services, Inc. continue to work towards implementing procedures established in the prior year as part of the corrective action plan for prior year finding. ChesPenn Health Services, Inc. should ensure new procedures cause all patient files to be maintained and to be completed fully. Views of Responsible Officials ChesPenn Health Services, Inc. will continue to monitor the process of maintaining paper copies of all sliding fee scale patient files in each office as a back-up to potential electronic system failures for scanning patient's records. In addition, ChesPenn Health Services, Inc.'s Compliance Officer and Chief Operating Officer will conduct random monthly audits of sliding fee applications at all three locations. Results from the audits will be presented to the site Office Manager who will then conduct staff training sessions with the Patient Service Representatives. The audit and subsequent training will include a review of the following parameters for proper documentation and sliding fee scale determination: Identification: o State issued driver's license o State issued or state recognized identification card o School identification o Government issued passport o If married, a copy of spouse's identification as well Social Security Cards: o For the applicant o For the spouse, if married o For all dependents 18 years of age or younger o For a college student, up to 23 years of age with college documentation o If a social security card is not available for a child, a birth certificate will be accepted Paystubs: o One recent pay stub, if married a copy from spouse as well o Benefits statement from social security, if married from husband and wife o Awards letter for unemployment, if married from husband and wife o Self-employed - Last year's income tax statement o If paid in cash, a letter from the employer, on company letter head that states the hourly rate and hours worked o If the letter is handwritten, the letter must be notarized o When an individual has no source of income and has no insurance, they are required to fill out the information on the front and the back of the sliding fee scale form. Photo identification and social security cards are required
Finding Number: 2022-001 Assistance Listing Numbers: 93.224, 93.527 Cluster/Program Name: Health Center Program Cluster [including COVID-19 funds] Federal Agency: U.S. Department of Health and Human Services Federal Award Identification Numbers: Various Federal Award Years in Cluster: Various grant periods: February 1, 2019-January 31, 2020; February 1, 2021-January 31, 2022; February 1, 2022 to January 31, 2023; April 1, 2020 to March 31, 2021; April 1, 2021 to March 31, 2023 Finding Type: Significant Deficiency Compliance Requirement: Special Tests and Provisions Pass-Through Entity: None Questioned Costs: $0 ChesPenn Health Services, Inc. did not maintain complete patient files for all patients who received healthcare under the sliding fee arrangement. Condition and Context 4 out of 40 selected patients receiving healthcare under the sliding fee arrangement application had incomplete documentation of supervisory review. The sample was not a statistically valid sample. Criteria Under the compliance requirements listed in the Office of Management and Budget (?OMB?) Compliance Supplement for the Health Center Program Cluster, health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted based on the patient?s ability to pay. Cause As a result of the COVID-19 pandemic, controls that have historically been in place over maintaining patient files in the office were not followed in all instances. Historical controls were not followed based on COVID-19 epidemic staffing shortages and constraints and provision of virtual services. As a result, there were some incomplete applications due to human error. Effect or Potential Effect For 4 out of 40 patients selected for testing, the internal control procedure to perform additional supervisory check of the sliding fee discount application was not formally documented. This was considered a deficiency in internal controls. Recommendation We recommend that ChesPenn Health Services, Inc. continue to work towards implementing procedures established in the prior year as part of the corrective action plan for prior year finding. ChesPenn Health Services, Inc. should ensure new procedures cause all patient files to be maintained and to be completed fully. Views of Responsible Officials ChesPenn Health Services, Inc. will continue to monitor the process of maintaining paper copies of all sliding fee scale patient files in each office as a back-up to potential electronic system failures for scanning patient's records. In addition, ChesPenn Health Services, Inc.'s Compliance Officer and Chief Operating Officer will conduct random monthly audits of sliding fee applications at all three locations. Results from the audits will be presented to the site Office Manager who will then conduct staff training sessions with the Patient Service Representatives. The audit and subsequent training will include a review of the following parameters for proper documentation and sliding fee scale determination: Identification: o State issued driver's license o State issued or state recognized identification card o School identification o Government issued passport o If married, a copy of spouse's identification as well Social Security Cards: o For the applicant o For the spouse, if married o For all dependents 18 years of age or younger o For a college student, up to 23 years of age with college documentation o If a social security card is not available for a child, a birth certificate will be accepted Paystubs: o One recent pay stub, if married a copy from spouse as well o Benefits statement from social security, if married from husband and wife o Awards letter for unemployment, if married from husband and wife o Self-employed - Last year's income tax statement o If paid in cash, a letter from the employer, on company letter head that states the hourly rate and hours worked o If the letter is handwritten, the letter must be notarized o When an individual has no source of income and has no insurance, they are required to fill out the information on the front and the back of the sliding fee scale form. Photo identification and social security cards are required