What is Family Size?
Family size is defined as a group of two or more persons related by birth, marriage, adoption, or legal partnerships (i.e. domestic partnerships) who live together; all such related persons are considered as members of one family. This includes students, regardless their residence, who are supported by their parents or others related by birth, marriage, or adoption, or legal partnerships (i.e. domestic partnerships). Self-declaration is used for family size.
What counts as Income?
Income is defined as total annual cash receipts, before taxes from all sources, including wages and salaries before any deductions, net receipts from self-employment, regular payments from social security, unemployment compensation, alimony, child support, military family allotments, pensions, and regular insurance or annuity payments, dividends, interest, net rental income. Documentation to support income are pay stubs, recent federal tax return, copy of W2 form, gross income verification completed by the employer, and/or copies of bank statements. Other documentation may be used if needed and approved by Clinic Manager, CFO, and/or CEO. If you cannot provide income information, you may self- declare your income by filling out the self-declaration form.
What will I owe?
If you decline to apply for the Sliding Fee Scale or are not eligible, and do not have insurance coverage, you are considered ‘full fee.’ If you are determined to be ‘full fee,’ you will be expected to pay $100 at time of visit and the remaining balance will billed to you.
Patients who do qualify for the Sliding Fee Scale will have a set share of cost for Medical and Behavioral Health services, and a percentage share of cost for dental services, based on their family size and income. The reception team will review the family size and income information and provide you with what you can expect to pay for your share of cost. Your share of cost is due at time of service.
How do I apply?
Please complete, sign and return this form. If you need help, our staff can assist you to complete the application. You can make an appointment and receive services before your application is approved.