Sliding Fee Scale Application

Sliding Fee Scale Application 2025/2026

Apply for a reduced fee based on your financial situation and household size.
Full Name

First NameLast Name
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Previous Names Used
Email Address
example@example.com
Last 4 Digits of SS Number
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Modified Adjusted Gross Income Amount from 2025 1040 tax return
If you did not file taxes or are unable to provide this information, please refer to other income verification options on the bottom of this page.
Household Size
Household Member 1
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Household Member Income Amount
Pay Frequency
Household Member 2
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Household Member Income Amount
Pay Frequency
Household Member 3
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Household Member Income Amount
Pay Frequency
Household Member 4
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Household Member Income Amount
Pay Frequency
Household Member 5
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Monthly Household Income (USD)
Pay Frequency
Total Annual Income of Household Members
A household member is someone who lives with you at least part time that you support financially.
Upload Proof of Income or Supporting Documents

Income verification documents can include any of the following: 1040 Tax Return, a W-2 form, three months of pay stubs, 3 months of bank income deposits, a signed and dated letter from employer with amount payment amount, Social Security/Disability award letter, or a signed and dated letter from you stating your unemployment status if that is the case.
Cancelof
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please read and sign document.

I do hereby affirm that the information provided on this application is true and correct to the best of my knowledge. If acceptance in the Sliding Fee Scale program is obtained under this application, I will comply with all rules and regulations of the program. Sawtooth Mountain Clinic will not be responsible for bills which may incur that are outside the scope of the Sliding Fee Scale program. Sawtooth Mountain Clinic, Cook County North Shore Health and the Oral Health Task Force may share my information to determine eligibility. I hereby acknowledge that I have read and understand this foregoing disclosure with my signature.
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Sliding Fee Scale Application 2025/2026