Publications & Forms
PATIENT DISCOUNT ELIGIBILITY FORM
Discount Policy: Daughters of Charity Health Centers determine eligibility for patient discounts based on the patient’s household assessment determined by family income and family size.
Payment Policy: Daughters of Charity Health Centers collect all applicable payments, co-payments and/or deductibles at time of service.
Daughters of Charity Services of New Orleans is committed to improving the health status of our community. We continue to advance our long tradition of health ministry through the development of a values-driven organization dedicated to primary care and preventive health services, addressing the needs of the total individual – body, mind and spirit.
We provide discounts to uninsured patients based on family size and household income. In order to comply with federal healthcare regulations and guidelines, we are required to collect proof income from all patients that wish to qualify for our sliding fee scale.
Please note that the following documents are the only documents that we will be accepting as proof of income.
Payroll Check Stubs (1 to 2 most recent, must be within last 30 days)
Benefits Checks (Food Stamp Budget Letter, Unemployment checks)
Insurance Checks (workers compensation)
Bank Statements (3 monthly Statements-Must show company name or consistent deposits)
SSI Check/Retirement/Award Letter
Tax Returns or W-2 Form
Court Ordered Child Support Letter
Thank you for choosing us for your health care needs. We look forward to serving you!