CHCCW ensures that patients have access to affordable services, regardless of their ability to pay. The Sliding Fee Discount Program reduces financial barriers by applying discounts based on household income and size in relation to current Federal Poverty Guidelines, affirms consistent and equitable application of fees and discounts, and reinforces CHCCW's commitment that no patient is denied care due to financial hardship.

Call 307-233-6000 and press option #3 to request an application.

Apply online at http://www.CHCCW.org. Navigate to the "Financial Services" tab and click on "Sliding Fee Application".

Stop by any CHCCW location for a paper application.

• Documentation of proof of income is required. The application will not be processed until all necessary information is received.
• The Casper facility is the only location that can accommodate a face-to-face appointment. Please call 307-233-6000 if you wish to schedule a slide appointment.
• Once the application is complete, return to us via fax (307-233-6089), email (slide@chccw.org), or drop off the paper application to any CHCCW location. Please include all required documentation with your application. Incomplete applications or applications missing the required documentation will be denied until the necessary information has been received.
• CHCCW Staff may request additional documentation to verify eligibility. Any false statements or attempt to deceive will result in a denial for eligibility and no discount is applied.

All applicants will receive a letter with the determination of the application:

Approved The letter will state the level of slide the application qualified for, effective and end dates, and include an explanation of benefits.

Denied The letter will state the reason for the denial. You may reapply anytime you obtain the proper documentation or if there is a change in household income and/or family size.

Please keep the letter for future verification. It is recommended to make note of the end date and reapply 30 days prior to avoid any lapse in slide coverage.

If you have not been contacted within 10 business days, please call 307-233-6000, option #3 for status updates and/or verification.

All CHCCW patients are expected to pay at the time of service.

Household Size: All individuals who can be claimed on the guarantor's tax return or those who share gross income, regardless of residence.

Income: Total gross earnings received by household individuals aged 18 or older, including wages, benefits, and other sources.

4. Include copies of proof of income with this application.

Examples of proof of income: Federal tax returns (most recent year), pay stubs (covering most recent 30-day period), Agency letters (e.g., Social Security, Veterans Affairs, Social Services), Unemployment verification, Student Grants, Court documents (child support, alimony), Retirement statements, Employer letter verifying gross income and frequency of pay, written third-party statement of support.

Appointments 10 days prior to completed application date will be included in slide discount.

I, the undersigned, have completed this application for CHCCW's sliding fee eligibility and confirm that this information is true and correct to the best of my knowledge. I further understand that if my economic situation changes, I am solely responsible for reporting the change upon my next visit. All information I provided within this application is truthful, correct and is subject to confirmation by CHCCW. Any false statements or attempt to deceive will result in a denial for eligibility and no discount is applied.

CHCCW allows patients to self-attest only when no other documentation can be provided. There may be restrictions on how many times self-attestation is accepted before proof of non-filing is required.

I, the undersigned, declare that I have not had any income in the last 30 days and understand any false statements or attempt to deceive will result in a denial for eligibility and no discount is applied.