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Sliding Fee Scale

This Sliding Fee Scale Is Effective As Of 1/01/2006

 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:

 

 

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 $3,260.  For the 20% category, the patient will be responsible for 20% of the bill or $10.00, whichever is higher.  In the 0% category, the patient is asked to pay $10.00 for office visit, $10.00 for lab work, 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 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.
                                           Last updated 12/28/05