Sliding Fee Eligibility

  • Sliding Fee Eligibility

  • Mainline Health Systems, Inc. Sliding Fee Program is for patients and their families to pay according to their income. The Federal Poverty Scale is used for determination of level. Please complete the following information so that Mainline Health Systems will be able to determine your eligibility for discounted services. You will be reassessed for the sliding scale annually, and you will be required to provide updated proof of income.

  • Please select from the following options*

  • Household Family Member 1- Head of Household

  • Date of Birth- Head of Household
     - -
  • Head of Household's Relationship to Applicant
  • Are there additional family members in the household?
  • Date of Birth
     - -
  • Relationship to Applicant
  • Are there additional family members in the household?
  • Date of Birth
     - -
  • Relationship to Applicant
  • Are there additional family members in the household?
  • Date of Birth
     - -
  • Relationship to Applicant
  • Are there additional family members in the household?
  • Date of Birth
     - -
  • Relationship to Applicant

  • Income Verification

  • Rows
  • Do you file a tax return?
  • Do you have healthcare insurance?

  • Proof of Income Documentation Required

    Eligible documents include:

    Tax Return

    Letter from employer stating earnings

    Letter from pastor stating no income

    Bank Statements showing deposits (unemployments, Social Security, Food Stamps, or other public assistance)

    W-2's

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