As a Federally Qualified Health Center, we offer sliding fee scale based on family size and income. Proof of income and family members are required by law to complete the application process.
To qualify for a sliding fee discount, please bring the following information with you to register at our centers:
- Proof of income for every household member. Income includes salary and wages, social security benefits, pensions, disability, veteran’s benefits, unemployment compensation, retirement, child support or alimony payments. Proof of income may include
- paycheck stubs for one month’s employment, or
- a copy of your tax form reporting your income if self-employed,or
- a bank statement (if you receive direct deposit) for social security or pension, or
- letter from social security administration
If you report no income, you will need the Support Form completed and signed by the person who pays living expenses.
- A Picture I.D.
- Proof of residence (for example, a bill addressed to you) if address is not on picture ID or is different.
- Insurance card(s), including Medicaid and Medicare (if applicable). Parents or guardians must apply for Medicaid or CHIP for all children 18 years and younger that are uninsured.
- Household member information, including names, social security number, and date of birth.
Sliding fee scale is calculated based on family size and income:
|Family Income per Poverty Guidelines||Sliding Fee Discount|
|100% and below||Nominal Fee|
|Above 200%||No discount|
Federal Poverty Guidelines 2010
For more information call (662) 651-4685.