Rural Health Care, Inc 2026 Sliding Fee Application

Rural Health Care, Inc Sliding Fee Application

Effective through May 31, 2027
Rural Health Care, Incorporated (RHCI) offers a sliding fee discount program to assist registered patients of the health center with paying their fair share of the household’s medical, dental and behavioral health care related expenses. The sliding fee is determined based on household size and income.

The continuation of the program depends upon each patient making reasonable efforts to pay their portion of visit charges. You may qualify for the discount to be applied to a visit prior to the date your application is received if the proper documentation is provided. Incomplete applications will be considered “void” after 30 days and a new application will be required if you still desire consideration for the program.

Even if you have health insurance, you might still qualify for the Sliding Fee Discount Program! If you do have health insurance, please present your card to the front desk at the time of your visit.

RHCI does not discriminate on the basis of gender, age, race, color, religion, national origin, handicap, parity, marital status, political beliefs or ability to pay.

ALL INFORMATION WILL BE KEPT CONFIDENTIAL.
Which Access Health location do you visit most often?
Patient Information

or Head of Household if patient is under 18
Name*

First NameLast Name
Other Name (if applicable)
Other name you may go by
Address*

Mailing Address

Street Address Line 2

CityState:

Postal / Zip Code
Home Phone Number
Format: (000) 000-0000.
Cell and/or Work Phone Number
Format: (000) 000-0000.
Email
example@example.com
Date of Birth*

MonthDayYear
Date
Preferred Method of Contact*
Please Pick One
Marital Status
Please Pick One
Household Size

List all persons living in the household including the applicant

Rows	Full Name	Relation to Applicant	Date of Birth
Applicant
Household Member 1
Household Member 2
Household Member 3
Household Member 4
Household Member 5
Household Member 6
Household Member 7
Household Member 8
Household Member 9

Income Documentation Checklist

Check all income verification items that should be included in your application
Please include one of the following for each member age 18 and older

Tax ReturnW-2Two Recent PaystubsZero Income Attestation
Please include documentation for ALL other types that are applicable

Social SecurityPension/Veterans' BenefitUnemployment CompensationAlimonyChild SupportRental IncomeInterest/Dividends
Click here to upload scans/pictures of your income verification listed above

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NOTE: To comply with federal regulations, in order to give you a discount on medical services, it is necessary for us to ask some personal questions. Information will be kept in strict confidence.

If after-tax checks are used as proof of income, 36.5% will be added to the total to account for the difference between gross and net income. Your annual income and your household size will be used to calculate your discount.
A $25.00 nominal fee will be due at the time of each visit regardless of sliding fee eligibility.

I, the undersigned, agree that RHCI may contact each source of income for all persons working in the above-mentioned household. I also agree to notify the clinic within thirty (30) days if any change in financial status.

I understand that verification of income is mandatory. I understand and agree that services will only be discounted after the appropriate means of proof of income is provided. I understand it is necessary to reapply and update financial and/or household member and financial status at least annually to ensure RHCI maintains updated information.

I attest that the information set forth in this application is true and complete. I understand that any misrepresentation or omission may be grounds for rejection of consideration for, or termination of, any sliding fee discount. I acknowledge that it is my duty, in a timely fashion, to amend the responses and information I have provided if I come to know that the response or information was incorrect when given or, though accurate when given, the response or information is no longer accurate.
Applicant’s Signature
**Proof of income MUST accompany application. Application will not be processed without documents**
Should be Empty:

Rural Health Care, Inc Sliding Fee Application

Patient Information

Household Size

Income Documentation Checklist