© 2010 FMF, Inc.

The sliding fee scale 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 scale 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 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 portion

              of the bill you will pay.

 

For each additional family member over 8 add $3,740. For the 20% category,

the patient  will be responsible for 20% of the bill or $20, whichever is higher.

In the 0% category, the patient is asked to pay $20 for office visit, $20 for

routine lab work, $20 for x-ray,  and $10 for injections.

                  (0%  fees scheduled to change October 1, 2009)

 

Download Fee Scale:              PDF                        Microsoft Word   

 

Download Application:           PDF                        Microsoft Word  

 

* 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.

 

© 2010 FMF, Inc.

Made by Serif

              Sliding Fee Scale