Sliding Scale Fee for Service Program
Sliding Scale Fee Form:
Disclaimer
Eligibility for this program is based on financial need.
The information contained in this form is confidential and used for administrative purposes only. This document will be stored in your financial section of your medical record. It is not used for reporting census, immigration or any other documentation purposes. It is used solely to determine your eligibility for the Sliding Fee Scale Discount.
Sliding Fee Discount Income Verification Guidelines
Please complete Sliding Fee Discount Application entirely. Please sign and return completed application and proof of income information to the health center within 14 days of the initial visit. Discount will start on the day proof of income is received.
Discounts will be based on household size and income. Health First CHC recognizes families do not always fit the traditional model. Health First identifies the definitions of a household, family and income as below:
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Household consists of all the persons who occupy a house or apartment. Adult children living at home who are no longer dependent are considered a separate household. Roommates who share living arrangements but are not tied to one another through marriage, children or similar relationships are considered separate households. Those living with a friend or relative during a time of need, are also considered a separate household.
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According to the Census Bureau a family is defined as a group of two people or more (one of whom is the householder) related by birth, marriage, or adoption and residing together; all such people (including related subfamily members) are considered as members of one family.
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Income includes: earnings, unemployment compensation, workers' compensation, Social Security, Supplemental Security Income, public assistance, veterans' payments, survivor benefits, pension or retirement income, interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources. Noncash benefits (such as food stamps and housing subsidies) do not count.
Patients will not be discriminated based on age, gender, race, creed, disability, national origin or insurance status. Dignity, confidentiality and respect will be given to all who seek and/or are provided charitable services.
You must provide at least one of the following:
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Prior year W‐2.
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Two most recent pay stubs.
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Letter from employer stating patient’s income. Health First would prefer document be on letterhead and must include employer’s name, address and phone number.
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Form 4506‐T (if W‐2 not filed).
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Form 1040, 1040A or 1040EZ.
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Social Security letter for fixed incomes such as social security, disability, pension, etc.
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SNAP benefits letter
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Free lunch school form, which must include household size and income.
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Most recent unemployment compensation documentation.
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Letter of reference on letterhead from any 501(c) (3) non‐profit organizations such as
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homeless shelters or churches.
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Self‐employed individuals will be required to submit detail of the most recent three months of income and expenses for the business.
There is a 30 day grace period from the date of your visit to the time the application needs to be returned. If the application is not returned within 30 days, you will be responsible for 100% of charges.
We will contact you in writing if you are denied for any reason.
If approved we will send you a letter identifying your assigned Slide Class. Please show the slide card to the receptionist at each visit. The Outreach Specialists will work with medical staff, pharmaceutical companies and local community resources to help provide medical and social needs, as needed. Outreach workers could utilize information from your application and income verification to apply for additional assistance, as needed.
Sliding Fee Discount Program
We serve all community members and offer services on a sliding fee schedule, based on income. This Sliding Fee Discount Program provides a mechanism that ensures services are available to all clients without regard for the person’s ability to pay. It provides a consistent and comprehensive set of eligibility guidelines for sliding fee discount management and a mechanism for collecting income level information for all patients, regardless of discount status.