Sliding Fee Scale Application Packet for Uninsured Patients at Compassion Health Toledo
Welcome, and thank you for choosing Compassion Health Toledo for your health care! Compassion Health Toledo is a faith based clinic providing high quality and compassionate medical care for all men, women and children, regardless of insurance, income, or ability to pay.
We require all of our patients who do not have insurance complete this Sliding Fee Scale Application” and provide specific documentation to verify your ability to pay. This information will only be used by the clinic to determine your fee.
If you do not provide income verification we may reschedule your medical visit or you will be charged 100% of the fee. We offer a 50% prompt pay discount if payment is made on the day of service.
Please note that some procedures, and some labs might have additional costs. Cost list available upon request.
Thank you for your cooperation. We look forward to serving you!
Sliding Fee Scale Eligibility Form
To determine your eligibility for our sliding scale and the amount you will be responsible for each visit, we must obtain verification of income ( See Below).
Providing at least one form of income verification is required to complete this sliding fee application:
Income Verification: must provide at least one of the following
- Tax filing form (most recent tax year)
- Paystubs (last month or last 30 days)
- Award or benefit letter (WIC, Food Stamps, Cash Assistance, etc.)
- Letter from employer stating wages
- Unemployment or Disability check stub (last month or last 30 days)
I have no income and am not currently receiving assistance from the government or another agency (like Social Security, Cash Assistance, Food Stamps, WIC, etc). You will be required to complete a Self Declaration Form