Sliding Fee for Service:

Patients that qualify financially based on their gross household annual income and family size using the federal guidelines for poverty will be granted a discounted fee for service.

Patients can refer to the sliding fee chart to determine what level for which you may qualify.  To apply for the sliding fee discount, please complete the ‘Financial Worksheet’ and the ‘Income Levels’ forms and bring in proof of financial status from all sources of income in your family.  One or more of the following are accepted:

• Tax forms from most recent year

• Pay check stubs for one month (preferably with year to date income provided)

• Office of Public Assistance benefit printout (example: food stamps)

• Fixed income statement (example: pension or bank statements showing deposits)

• Letter on agency letterhead verifyng financial status(example: Housing Authority)

• Student Grant Information/SARS

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If you are self-employed:

• Tax forms from most current year and current profit and loss statement

Present the completed forms and financial proof to the receptionist within two weeks of your appointment. The application will be then reviewed and you will receive notification of your discount.

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Sliding Fee Application: MS Word