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Board of Health P&P Manual, Section I <br /> Policy E,Attachment C <br /> Request for Waiver of Certain Fees <br /> Orange County Health Department <br /> • The Health Department's Fee and Eligibility Policy states: "The Health Director may not <br /> make exceptions to the Fee Policy except to accommodate specific situations" <br /> Section IV N.•Fees for Services <br /> • It is recognized by OCHD that in certain rare or unusual situations, a client's health <br /> and/or safety may be severely impacted by the inability to pay the sliding scale co-pay for <br /> services, pharmaceuticals, etc. In such cases the p3=evi ler- supervisor may submit this <br /> request for a—one-time waiver of fee(s)toby the Division44ealth Director. The Division <br /> Director will obtain Health Director approval. If proven to be homeless, client will be <br /> eligible for waiver until financial status changes. <br /> • Complete the following information: <br /> Division requesting waiver: ❑ PHSD ❑ Dental ❑ HPES ❑ Environmental Health <br /> Information submitted by: <br /> Employee Name Date Submitted <br /> Client Information <br /> Name: DOB: <br /> Last First MI <br /> Address: <br /> Street City State Zip Code <br /> Medicaid Eligibility Status: ❑ N/A ❑ Applied ❑ Has Not Applied ❑ Pending <br /> ❑ Presumptive ❑ Does Not Qualify <br /> Sliding Fee Determination: % ❑ N/A <br /> Request for Waiver of Fee <br /> SAMANAGERS WORKING FILES\BOH\Policies and Procedures\BOH Policy Manual\Current Policy Manual\I.E.Attachment <br /> C-Fee Waiver Updated 05 2016.docx <br /> Updated 5/2016,8/2020 <br />