Sliding Fee Scale Application Packet for Uninsured Patients at Compassion Health Toledo

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).

Income

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

Please list all Patient/ Guarantor employers for the last 12 months:

Please provide the following information for you and ALL of the people in your immediate family living in your home. For the purposes of this application, Family is defined as the patient, patient’s spouse and natural or adopted children under the age of 18 who live in the patient’s home and are supported by the same income. If a patient is under 18, please include the parent's income.

 

Income Table:

 

Thank you for completing the Sliding Fee Scale Application. For more information about Sliding Scale eligibility, please go to http://www.compassionhealthtoledo.org/  and locate "New Patient Resources" under the "More" tab. Your application will be reviewed within 48 hours of submission. Please contact us with any additional questions.

For Office Use Only:

Based on your income you quality for the sliding fee level of:

A. $10.00
B. $20.00
C. $30.00
D. $40.00
No sliding fee discount for greater than 200% FPL 

Effective Date: ____________________

Note:____________________________________________________________________________

You are responsible to pay this amount to Compassion Health Toledo at each medical appointment visit. Please note, some procedures, like ultrasounds, and some labs, etc. may have additional charges, which you will be billed for and will be responsible for paying.

If you have any changes to your income or insurance status, you are OBLIGATED to notify us as soon as possible so we can keep you information updated and accurate.