What is a Sliding Fee Scale?

It is the policy of CHCCW to offer a board approved Sliding Fee Scale Discount (SFSD) program to all individuals and families with annual incomes at or below 200% of current Federal Poverty Guidelines. No aspect of the SFSD, including the procedures for assessing patient eligibility, or the procedure for collecting payments, will create barriers to health care services. The SFDS is made available to reduce barriers to care for patients that are uninsured or underinsured. The SFDS is developed and reviewed annually based on community need and changes in the health care community.

An SFSD is available for services at CHCCW and is available to patients regardless of their ability to pay.

Why do we have a Sliding Fee Scale?

Community Health Center uses a Sliding Fee Scale so that we can reduce financial barriers to care for medical, behavioral, pharmacy, and dental costs in our community. Every patient is expected to carry some portion of the cost or nominal fee that is affordable for the patient. By bringing your co-pay and making payments on your bill, you help CHCCW keep our doors open to all members of the community.

Who is eligible for the Sliding Fee Scale?

This SFSD is a non-discriminatory and every patient is eligible to apply. If you fall within the household and income requirements, you will automatically be placed on the appropriate slide.

How do I apply for the SFSD?

Patients are encouraged to call to schedule an appointment with patient services. Financial information must be provided on or before the day of visit in order to qualify/obtain an SFSD. You will need to provide your household income and size. If you are found to be eligible for the SFSD, you will be asked to fill out a sliding fee application.

What is considered household income?

The types of income used to determine eligibility for SFSD include, but are not limited to, the following:

  • Employment and cash earnings
  • Unemployment compensation
  • Worker’s Compensation
  • Social Security
  • Supplemental Security Income
  • Public assistance
  • Veterans’ payments
  • Survivor benefits
  • Pension
  • Retirement income
  • Rents
  • Royalties
  • Income from estates
  • Interest/Dividends
  • Trusts
  • Educational assistance (scholarships and grants used for living expenses)
  • Alimony
  • Child Support
  • Assistance from outside the household
  • Misc. sources

 

What information do I need to bring to CHC to receive SFSD?

Acceptable forms of proof for determining income include, but are not limited to, the following:

  • Income Tax Return – A signed copy of the most recent tax return showing Adjusted Gross Income (AGI)
  • Paycheck Stubs – Most recent pay stub(s) indicating gross pay
  • Agency Letter – A letter from the Social Security Administration, Veterans Administration, or Social Service Agency (i.e., AFDC, Foot Stamps, WIC) indicating income level
  • Unemployment Verification – Paperwork from the Employment Securities Commission (ESC), proving unemployment status and the amount of unemployment compensation being received
  • Court Documents – Official documents citing child support, or alimony as awarded by a judge accompanied by a statement of child support enforcement stating amount received *In the situation of spousal separation, a legal document such as a legal separation or divorce filing will be requested from the patient; but not required if self-declared
  • Official Paperwork – Paperwork documenting retirement, disability, and/or SSI benefits
  • Employer Letter – For those not receiving an actual pay check, a letter from the patient’s employer detailing current gross income and frequency of pay periods may be accepted. Contact information on company letterhead must be provided so that the information can be verified
  • No Job/Other Income Source – A current-dated letter from an agency, friend, relative, or past employer, who knows the situation and is NOT living with the applicant, which includes the writer’s name, address, and phone number
  • Self-Declaration Is acceptable if no other information can be provided

FLUORIDE TREATMENT:

BOOK YOUR APPOINTMENT

We are offering a FREE fluoride treatment with any service while quantities last.

This offer is for new and existing clients. Through a grant from the Henry Schein corporation, as well as supplies donations from Patterson Dental, CHCCW has received Free Fluoride treatments. CHCCW will be providing fluoride treatments free of cost to help prevent tooth decay and improve oral health. Call 307-233-6000 to book your appointment.