|

Current year's tax form (1040 form)

2 current pay stubs

1 unemployment stub

Letter from employer on letterhead that states your salary or wages

Most recent rent receipt

If none of the above are available, you must provide a letter of reference from any 501(c)(3) (non-profit) organization on their letterhead (for example, your church).
Discount levels for qualifying patients based upon household size are shown below.
Percent shown is the amount of discount.
Effective February 1st, 2007 Family Health
Centers will require a minimum fee of $15.00 for class 6 patient visits.
|
FHC - Sliding Fee Scale |
|
ANNUAL INCOME LEVEL |
|
Effective January 28, 2008 |
|
Family |
Class 6 |
Class 5 |
Class 4 |
Class 3 |
Class 2 |
Class 1 |
|
Size |
PAYS Min Fee |
PAYS 20% |
PAYS 40% |
PAYS 60% |
PAYS 80% |
PAYS 100% |
|
1 |
$0 - |
$10,401 - |
$13,001- $15,600 |
$15,601 - $18,200 |
$18,201 - $20,799 |
$20,800 - |
|
$10,400 |
$13,000 |
UP |
|
2 |
$0 - |
$14,001 - |
$17,501- $21,000 |
$21,001 - $24,500 |
$24,501 - $27,999 |
$28,000- |
|
$14,000 |
$17,500 |
UP |
|
3 |
$0 - |
$17,601 - $22,000 |
$22,001 - $26,400 |
$26,401 - $30,800 |
$30,801 - $35,199 |
$35,200- |
|
$17,600 |
UP |
|
4 |
$0 - |
$21,201 - $26,500 |
$26,501- $31,800 |
$31,801 - $37,100 |
$37,101 - $42,399 |
$42,400- |
|
$21,200 |
UP |
|
5 |
$0 - |
$24,801 - $31,000 |
$31,001- $37,200 |
$37,201 - $43,400 |
$43,401 - $49,599 |
$49,600 - |
|
$24,800 |
UP |
|
6 |
$0 - |
$28,401 - $35,500 |
$35,501 - $42,600 |
$42,601 - $49,700 |
$49,701 - $56,799 |
$56,800 - |
|
$28,400 |
UP |
|
7 |
$0 - |
$32,001 - $40,000 |
$40,001 - $48,000 |
$48,001 - $56,000 |
$56,001 - $63,999 |
$64,000- |
|
$32,000 |
UP |
|
8 |
$0 - |
$35,601- $44,500 |
$44,501 - $53,400 |
$53,401 - $62,300 |
$62,301 - $71,199 |
$71,200 - |
|
$35,600 |
UP |
|
NOTE: For family units of more than 8 members, add $3,600 for each
additional member. |
|
|
|
TOP |
|
|
|
FHC - Sliding Fee Scale |
|
MONTHLY INCOME LEVEL |
|
Effective January 28, 2008 |
|
Family |
Class 6 |
Class 5 |
Class 4 |
Class 3 |
Class 2 |
Class 1 |
|
Size |
PAYS Min Fee |
PAYS 20% |
PAYS 40% |
PAYS 60% |
PAYS 80% |
PAYS 100% |
|
1 |
$0 - |
$868 - |
$1,085 - |
$1,302 - $1,517 |
$1,518 - $1,733 |
$1,734 - |
|
$867 |
$1,084 |
$1,301 |
UP |
|
2 |
$0 - |
$1,168 - |
$1.460 - $1,751 |
$1,752 - $2,042 |
$2,043 - $2,333 |
$2,334 - |
|
$1,167 |
$1,459 |
UP |
|
3 |
$0 - |
$1,468 - $1,834 |
$1,835- $2,201 |
$2,202 - $2,567 |
$2,568 - $2,933 |
$2,934 - |
|
$1,467 |
UP |
|
4 |
$0 - |
$1,768- $2,209 |
$2,210- $2,651 |
$2,652 - $3,092 |
$3,093 - $3,533 |
$3,534 - |
|
$1,767 |
UP |
|
5 |
$0 - |
$2,068 - $2,584 |
$2,585 - $3,101 |
$3,102 - $3,617 |
$3,618 - $4,133 |
$4,134 - |
|
$2,067 |
UP |
|
6 |
$0 - |
$2,368 - $2,959 |
$2,960 - $3,551 |
$3,552 - $4,142 |
$4,143 - $4,733 |
$4,734 - |
|
$2,367 |
UP |
|
7 |
$0 - |
$2,668 - $3,334 |
$3,335 - $4,001 |
$4,002 - $4,667 |
$4,668 - $5,333 |
$5,334 - |
|
$2,667 |
UP |
|
8 |
$0 - |
$2,968 - $3,709 |
$3,710 - $4,451 |
$4,452- $5,192 |
$5,193- $5,933 |
$5,934- |
|
$2,967 |
UP |
|
NOTE: For family units of more than 8 members, add $300 for each
additional member. |
|
|
|
TOP |
|
|
|
FHC - Sliding Fee Scale |
|
BI-WEEKLY INCOME LEVEL |
|
Effective January 28, 2008 |
|
Family |
Class 6 |
Class 5 |
Class 4 |
Class 3 |
Class 2 |
Class 1 |
|
Size |
PAYS Min Fee |
PAYS 20% |
PAYS 40% |
PAYS 60% |
PAYS 80% |
PAYS 100% |
|
1 |
$0 - |
$401 - $500 |
$501- $600 |
$601 - $700 |
$701 - $800 |
$801- |
|
$400 |
UP |
|
2 |
$0 - |
$539 - $673 |
$674 - $808 |
$809 - $942 |
$943 - $1,077 |
$1,078 - |
|
$538 |
UP |
|
3 |
$0 - |
$678 - |
$847 - $1,015 |
$1,016 - $1,185 |
$1,186 - $1,354 |
$1,355 - |
|
$677 |
$846 |
UP |
|
4 |
$0 - |
$816 - |
$1,020 - $1,223 |
$1,224 - $1,427 |
$1,428 - $1,631 |
$1,632 - |
|
$815 |
$1,019 |
UP |
|
5 |
$0 - |
$955- |
$1,193 - $1,431 |
$1,432 - $1,669 |
$1,670 - $1,908 |
$1,909 - |
|
$954 |
$1,192 |
UP |
|
6 |
$0 - |
| |