Sliding Fee Scale

Sliding Fee Scale Discount Program

It is possible you may be eligible for a discount on services we offer at our center, if you qualify for our sliding fee scale discount program. Sliding fee discount program is based on your family household size, annual income and current federal poverty level guidelines. Discounts are available for applicants whom household and income fall below the 200% of the federal poverty level guidelines.

• The discount you are certified for will be effective for one year from the date of certification.

• The discount will apply to only the services received at Family Circle of Care, that includes:

▪ Medical services

▪ Procedures

▪ Laboratory services

▪ Injections/Vaccines

• The following services are not included in the sliding fee scale discount program:

▪ DME

▪ Contraceptive products

▪ Circumcisions

▪ Hospital charges

▪ Physician fee for Delivery

▪ Outside Labs

▪ Pathology

• The sliding fee scale discount program does not take place of current insurance you may have or are eligible for.

To Apply

The sliding fee scale application must be completed along with required proof of income and family size. Please use the checklist for required information. Please note that if the application is not filled out completely or if there is missing information, you will not be certified for the sliding fee scale discount program.

➢ Required Information

Proof of Household (need an identification of everyone in the household)Photo identification (government issued ID)Driver’s licenseBirth certificatePassportCopy of most recent tax return showing the list of those in household

Proof of Income (need one of the following for all income in household)Last 4 paycheck stubs (4 consecutive periods)Last year’s tax returnLetter from Employer (must be on an organization letterhead, and have a signature from employer, current date, and employer phone number)Self-Employment Verification FormSocial security award/benefit letterUnemployment benefit check/award letterWorker’s compensation check/award letterAlimony/Child supportNO source of income – Provide a letter that states your current financial status, or a form of financial assistance can be provided to you by our front office. Letter from Minister/Pastor/Clergy, Director of Homeless Shelter, Landlord, or Social/Case worker (must be on an organization letterhead)

Signature

Full Name

Date

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