Access Family Health Services

Sliding Fee

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.

Application for sliding fee discount is available for download

To qualify for a sliding fee discount, please bring the following information with you to register at our centers:

  1. 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 income is paid in cash, please ask your employer to complete the Verifications of Earnings Form.
    If you report no income, you will need the Support Form completed and signed by the person who pays living expenses.
     
  2. A Picture I.D.
     
  3. Proof of residence (for example, a bill addressed to you) if address is not on picture ID or is different.
     
  4. 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.
     
  5. 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
100-125% 80%
125-150% 60%
150-175% 40%
175-200% 20%
Above 200% No discount
Federal Poverty Guidelines 2010

https://www.cms.gov/MedicaidEligibility/Downloads/POV10Combo.pdf

For more information call (662) 651-4685.
 


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