Discount Application

Sliding Fee Application

It is the OB/GYN Associates of Erie policy to provide essential services regardless of the patient’s ability to pay. Discounts are offered depending upon family income and size. Please complete the following information and return to our office to determine if you or members of your family are eligible for a discount. The discount will apply to all services received at this office, but not those services which are purchased from outside, such as reference laboratory testing, drugs, x-ray interpretation by a consulting radiologist, and similar services. In the hope that your economic health improves, discounts apply only to current, not future services. This form must be completed for each visit. All other payment resources must be exhausted including all third-party payments from insurance, Federal, and State programs. Please inquire at the front desk if you have questions.