Sliding Fee Scale

   Our sliding-fee discount is for anyone whose household income is less than 200% of the Federal Poverty Guidelines.  “Household”  includes all people living in the same house or apartment even if they are not related to you.

   After you fill out the Sliding Fee Scale Application we can tell how much we can discount your fee.  We can use this discount for any any amount due and for any services we offer. 

   We will give you the care you need no matter what you can pay today.

How to apply for our sliding fee discount:
Our front desk or billing staff can help you apply. Step one, asking about your household size and income, is always done as part of our check-in process.
To apply for a discount, we ask you to fill in a short form and show us proof of income. If you don’t have proof of income on your first visit, we can give you 30 days to show us the paperwork we need. 

What you need to bring for “proof of income”:
If you are EMPLOYED:
 A copy of last year’s income tax return.


Or  if you did not file a return:

a. W2 

or   

b. Pay stubs from last 30 days

or   

c.  Written statement from your employer

If you are NOT EMPLOYED:

a. Medicaid or Child Health Plus denial letter
b. Proof of Social Security income
c. Proof of Unemployment income
d. Proof of Disability income.
e. Proof of other income ( if you have it) like child support, alimony, or retirement pension

You will need to update our Sliding Fee Application Form every year.

 

SLIDING FEE APPLICATION FORM