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Available Forms

Self-Attestation Income Verification

If this is the first time you are submitting paperwork to SRCC, please also complete and submit the Intake/Pre-Appointment Form. This includes your contact information. Without this information, we will not be able to acknowledge your acceptance into the program. Thank you.

Snake River Community Clinic is required to verify the household income of patients accessing services.

Print Name
Print Name

I do hereby swear or affirm that the information provided on this application is true and correct to the best of my knowledge and belief. I agree that any misleading or falsified information, and/or omissions may disqualify me and my family from further consideration free services. I further agree to inform Snake River Community Clinic if there is a significant change in my income. I hereby acknowledge that I read and understand the foregoing disclosure.

Please read the above statement and acknowledge by typing your name here.
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