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
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.