Income Verification – Any family/household paid in cash and that cash paid is not included on the family/household tax return, You must provide a completed and signed Income Verification form from each employer and each non-employer (i.e., individuals, businesses and/or organization) for services including casual labor, day labor and/or domestic service (e.g. gardening, landscaping, housekeeping, daycare, babysitting, etc.).
Means of Support – If some or all of the family/household support comes from sources other than income (e.g., checking account(s), savings account(s), investment account(s), etc.) and/or the support cannot be easily determined, the family/household must provide statements for all accounts (e.g., checking account(s), savings account(s), investment account(s), etc.) covering the most recent month.
Letter of Support – If family/household gets support (cash and/or non-cash) from one or more sources (individuals, businesses and/or organization), a completed and signed Letter of Support form from each source providing cash and/or non-cash support.
Declaration of Shared but Separate Households – If family/household shares the same address with one or more other family/households for financial reasons but is otherwise separate, each family/household must complete and sign a Shared but Separate Household form. You can self-declare shared but separate household.
For example, Jane Doe, an uninsured patient, shares a house with her sister. The costs of maintaining occupying the house (i.e., rent or mortgage payment, insurance, property taxes, maintenance, utilities, etc.) are shared but all other living expenses are separate. Jane Doe can declare a shared but separate household when applying for SFSDP.
Patients with third party coverage – patients with third party insurance that does not cover or only partially covers fees for services may be eligible for the SFSDP. Depending on the Clinic and the third-party insurance contract agreements, the charge for each additional service will vary but that charge will never be more than maximum fee of the patient’s SFSDP group. The insurance plan’s co-pay may be lower than the SFSDP, in which case we will charge the lower amount.
For example, John Doe, an insured patient, receives a service that has an established fee schedule cost of $80. Based on John Doe’s insurance plan, the co-pay would instead be $60 for that service. John Doe applied for the SFSDP. Based on family/household income and size information provided, John Doe is at 150 percent of the FPL and falls into the SFSDP Group 3. Under the DFP, John’s established fee of $80 is discounted to a fee of $40 for this service. Rather than the $60 co-pay, John Doe pays no more than his SFSDP Group discount fee of $40 out-of-pocket, as long as this is not prohibited by the insurance contract terms.
See clinic team member for Sliding Fee Scale Discount Program application and other forms that are necessary to document your household income.