Sliding Fee Program
As a Federally Qualified Health Center (FQHC), ACCESS Family Care (ACCESS) is able to provide sliding fee discounts for self-pay patients who meet income eligibility requirements. Self pay patients may qualify for the discount program based on family size and proper documentation of all household income.
For eligibility, complete the SLIDE DISCOUNT APPLICATION and submit proof of household income. The following list is considered acceptable documentation of household income:
- a) Previous year's Federal Tax Return (Form 1040, 1040A, 1040EZ) OR previous year's W-2 Forms for each working person in household
- b) Two recent (previous two months) pay check stubs for each working person in household OR documentation by employer including date of hire, rate of pay, and hours per week on company letterhead OR notarized documentation by employer including date of hire, rate of pay, and hours per week
- c) Award letter from the Social Security Administration OR bank statement indicating direct deposit from the Social Security Administration
- d) Notification letter or check stubs from the Unemployment Office stating benefit amount
- e) Notification letter of pension, retirement or disability benefits received OR bank statement indicating direct deposits for pension, retirement or disability benefits
For more information, contact the ACCESS Family Care health center nearest you and visit with one of our friendly Patient Services Specialists.
Discount Program Application in English