United Community Foundation (UCF) is a private not for profit healthcare center. Standard charges have been established for all services provided. UCF is not a city or county clinic. Any additional costs including labs and X-rays will be an additional cost to the patient.

If I request sliding scale, I will be charged based on the total family income and the number of people in my household.

If I have Medicaid or Medicare the charges for my visit and the services received will be submitted

to Medicaid/Medicare for reimbursement to the healthcare center and assignment must be accepted. I will bring my current Medicaid/Medicare certification letter with me each time I visit the healthcare center.

I authorize my insurance benefits be paid directly to the healthcare center. Also, I understand

that I am financially responsible for any balance due. My signature below authorizes UCF and/or my insurance company to release any information required to process my claims.