Financial Assistance

To determine if you qualify for the discounted program, it is necessary to provide accurate information including submitting the required documentation about your family/household income and size (please see qualifying documents below). An approved application is good for 12 months and will expire at that time. You will need to re-apply with submit updated documentation regarding your family/household income and size. *Please note providing false information is fraud and if discovered all discounted services will be revoked and you will be responsible for the total amount of services received.*

 

What is considered income?

Income earning includes any amount received (direct deposit, check or cash) for worked performed (wages, salary, armed forces pay, commissions, tips, piece-rate payments, casual labor, day labor, domestic service (e.g., gardening, landscaping, housekeeping, daycare, babysitting, etc.) and cash bonuses earned and self-employed gross income.

 

Accepted Proof of Income Documentation

To accurately capture total household income, we need proof if you and/or your household members are currently:	Acceptable documents to provide with application
Working/Employed or Contracted     Not Working/Unemployed and/or receive any of these:	Pay stubs covering the last 4 weeks
	Income verification form signed by employer or contractor
	Bank statements showing direct deposits covering last two months
	The most recent monthly statements from unemployment compensation, workers’ compensation, social security, Medicaid Share of Cost, Supplemental Security Income, public assistance, veteran’s payments, survivor benefits, disability benefits, pension or retirement income.
Other income earnings that you may provide:​	Statements with interest, dividends, rents, royalties, income from estates and trusts, education assistance, alimony, child support, assistance from outside the household.

What determines family/household size?

Family/Household size can be one person, a group of people and/or one or more families living (or staying temporarily) at the same address and share common housekeeping responsibilities. Common housekeeping responsibilities means sharing at least one meal a day or share a common living area (e.g., living room, dining room, kitchen, etc.). Individuals in the family/household do not have to be related by blood or marriage. Individuals in the family/household includes distant relatives, friends, foster children, renters, roommates, resident domestic servants and/or guests/visitors staying longer than 30 calendar days.


Click here for a Sliding Fee Scale Eligibility form:  English   Spanish    Creole

Based on information provided about family/household income and size, the Federal Poverty Level range, will determine your sliding fee discount level.

Family Size	≤ 100%	>101% to 150%	>151% to 175%	176% to 200%	Over 200%
1	$15,060.00	$15,210.60 - $22,590.00	$22,700.60 - $26,355.00	$26,505.60 - $30,120.00	$30,270.60
2	$20,440.00	$20,644.40 - $30,660.00	$30,864.40 - $35,770.00	$35,974.40 - $40,880.00	$41,084.40
3	$25,820.00	$26,078.20 - $38,730.00	$38,988.20 - $45,185.00	$45,443.20 - $51,640.00	$51,898.20
4	$31,200.00	$31,512.00 - $46,800.00	$47,112.00 - $54,600.00	$54,912.00 - $62,400.00	$62,712.00
5	$36,580.00	$36,945.80 - $54,870.00	$55,235.80 - $64,015.00	$64,380.80 - $73,160.00	$73,525.80
6	$41,960.00	$42,379.60 - $62,940.00	$63,359.60 - $73,430.00	$73,849.60 - $83,920.00	$84,339.60
7	$47,340.00	$47,813.40- $71,010.00	$71,483.40 - $82,845.00	$83,318.40 - $94,680.00	$95,153.40
8	$52,720.00	$53,247.20 - $79,080.00	$79,607.20 - $92,260.00	$92,787.20 - $105,440.00	$105,967.20
For families/households with more than 8 persons, add $5,380 for each additional person.

Based on the revised Federal Poverty guidelines (https://www.federalregister.gov/documents/2024/01/17/2024-00796/annual-update-of-the-hhs-poverty-guidelines) effective January 17, 2024.

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.