Sliding Fee for Service:
Patients that qualify financially based on their gross household annual income and family size using the federal guidelines for poverty will be granted a discounted fee for service.
Patients can refer to the sliding fee chart to determine what level for which you may qualify. To apply for the sliding fee discount, please complete the ‘Application for the Sliding Fee Discount Program’ form and bring in proof of financial status from all sources of income in your family. One or more of the following are accepted:
- Tax forms from most recent year
- Pay check stubs for one month (preferably with year to date income provided)
- Office of Public Assistance benefit printout (example: food stamps)
- Fixed income statement (example: pension or bank statements showing deposits)
- Letter on agency letterhead verifying financial status(example: Housing Authority)
- Student Grant Information/SARS
If you are self-employed:
- Tax forms from most current year and current profit and loss statement
Present the completed forms and financial proof to the receptionist within two weeks of your appointment. The application will be then reviewed and you will receive notification of your discount.
Forms to download:
Please complete this form with attachments prior to your scheduled clinic appointment.
Vouchers for laboratory, radiology, and specialist care are available to patients who are enrolled in the GCHC sliding fee discount program. These vouchers entitle patients to a reduced cost of appropriate laboratory tests or x-rays, respectively, and/or a letter to a specialist worth $100.
Vouchers for laboratory work, x-rays, or specialists will not be paid for sliding fee discount patients who have other methods to pay for these ancillary services (i.e. medical insurance, workers compensation, Indian Health Service, Veterans Administration, etc.), unless warranted by the Medical Director and/or CEO (usually under emergency situations).
These vouchers offer a sizeable discount, but are not free. There will be at least a $20 copay per voucher. For specialist referrals, the balance of the work done over $100 is the responsibility of the patient unless special permission is granted by the CEO.
U.S. Poverty Guidelines 2017
|Persons in Family/Household||
100% of the Federal Poverty Guideline
200% of the Federal Poverty Guideline
For Families/Households with more than 8 persons, add $4,180 for each additional person.
For more details on U.S. Poverty Guidelines visit – http://aspe.hhs.gov/poverty/