Sliding Fee Discount

Parents and their three children enjoy a healthy family meal together

As a Federally Qualified Health Center, we are able to offer a discount on some services based on a patient’s household income and family size.

Sliding fee calculations are based on an applicant’s total annual income as provided by the complete Federal Income Tax return(s), W-2(s) or 1099(s), four most recent pay stubs, Social Security or Pension Income, Public Assistance award letters, and unemployment compensation.

In order to qualify, patients must show proof of income for all family members or individuals living in their household or individuals for whom they are financially responsible. If you do not have any source of income, please speak with a staff member.

Female doctor in uniform sitting at a glass table and typing on laptop.

Applicants should provide a copy of the following documents, if applicable:

  • Previous year’s tax return, W-2’s or 1099’s
  • Most recent pay stubs spanning four weeks
  • Social Security or Pension Income
  • Unemployment compensation
  • Public assistance award letters for each adult age 18 and over living in the household.

To begin the Sliding Fee Discount application process, simply download the form below, complete it, and take it with you to your next scheduled visit.