This Sliding Fee Scale Is Effective As Of
1/01/2008
WHO CAN QUALIFY
The
sliding fee is a discount of charges for those who either have no
insurance or who have insurance but have a high deductible. Also, it is
for those whose insurance does not cover provided services. Regardless
of whether you have insurance or not, you must still meet the income
guidelines.
The
sliding fee is a formula used to determine the availability of reduced
charges to patients who qualify according to the number in the family
and the average yearly income of the family. The scale is as follows:
|
# IN
FAMILY |
0%
(100%) |
20%
(125%) |
40%
(150%) |
60%
(175%) |
80%
(200%) |
100% (>200%) |
|
1 |
0
10,400 |
10,401
13,000 |
13,001
15,600 |
15,600
18,200 |
18,201
20,800 |
20,801 |
|
2 |
0
14,000 |
14,001
17,500 |
17,501
21,000 |
21,001
24,500 |
24,501
28,000 |
28,001 |
|
3 |
0
17,600 |
17,601
22,000 |
22,001
26,400 |
26,401
30,800 |
30,801
35,200 |
35,201 |
|
4 |
0
21200 |
21,201
26,500 |
26,501
31,800 |
31,801
37,100 |
37,101
42,400 |
42,401 |
|
5 |
0
24,800 |
24,801
31,000 |
31,001
37,200 |
37,201
43,400 |
43,401
49,600 |
49,601 |
|
6 |
0
28,400 |
28,401
35,500 |
35,501
42,600 |
42,601
49,700 |
49,701
56,800 |
56,801 |
|
7 |
0
32,000 |
32,001
40,000 |
40,001
48,000 |
48,110
56,000 |
56,001
64,000 |
64,000 |
|
8 |
0
35,600 |
35,601
44,500 |
44,501
53,400 |
53,401
62,300 |
62,301
71,200 |
71,200 |
HOW TO READ THE SLIDING FEE SCALE
Step 1: Locate the row corresponding to the number of individuals in
your family.
Step 2: Move to the right until you find the range containing your average annual income.
Step 3: Go to the top of that column. The percentage shown is the discount on your portion of the bill.
For each additional family member over 8 add $3,600. For the 20% category,
the patient will be responsible for 20% of the bill or $20.00, whichever is higher.
In the 0% category, the patient is asked to pay $20.00 for
a primary care office visit, $20.00 for a behavioral health office visit, and
$30.00 for a dental office visit. The
0% category will also be asked for $10.00 to
cover lab work,
should lab be necessary, and $10.00 for X-ray.
HOW DO I QUALIFY
To qualify for the sliding fee, you must fill out a form. These can be picked up at the clinic or printed by selecting the Sliding Fee
Application Form from this page.
You Must Provide Proof of Income by presenting at least
one of the items listed below;
-
Tax Forms from the most recent year
-
Paycheck stubs for one month, preferably with year to date income provided
-
Office of Public Assistance benefit printout (food stamp benefit history)
-
Fixed Income Statement (example: pension, social security or bank statement
showing deposits)
-
Signed personal letter verifying financial status, housing situation,
and how you cover expenses
-
Letter on Agency letterhead verifying financial status (example: Housing
Authority)
-
Student Grant Information
-
If you are self employed, tax forms from current year and a profit and
loss statement.
REMEMBER – All family income is to be included. Income is the AMOUNT
EARNED BEFORE TAXES ARE DEDUCTED.
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