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Patient Sliding Scale Program

What is the Sliding Scale?

Our mission is to insure that all patients and community members have 100% access to health care. To help make this possible we have created a sliding scale which allows us to adjust visit costs depending on the patient’s eligibility for the program.

How do I apply?

To apply for the sliding scale, contact one of our Financial Counselors and gather the following information for your appointment:

  • Proof of Gross Income for 1 Months’ Time (Paystubs, SSI, Disability, Unemployment, Pension, Child support, etc.)
  • Most Recent Tax Return (Used to verify household size - Schedule C Form is required for those who are self-employed.
  • DHS Eligibility Statement (If you are currently receiving aid from DHS or do NOT currently have any income.)

Sliding Scale A / Sliding Scale B / Sliding Scale C / Sliding Scale D
Medical Services / $20 Nominal fee / $30 Discounted fee / $35 Discounted fee / $40 Discounted fee
Behavioral Health Services / $1 Nominal fee / $2 Discounted fee / $2 Discounted fee / $2 Discounted fee
Vision Services
  • Eye Exam
/ $20 Nominal fee / $30 Discounted fee / $35 Discounted fee / $40 Discounted fee
  • Eye glass FramesLenses
/ Patient pays cost / Patient pays cost / Patient pays cost / Patient pays cost
Dental Services
  • Restorative
/ $20 Nominal fee / 50% Discount / 40% Discount / 30% Discount
  • Preventative
/ $20 Nominal fee / $30 Discounted fee / $35 Discounted fee / $40 Discounted fee
  • Lab
/ Patient pays cost / Patient pays cost / Patient pays cost / Patient pays cost

What is the difference in Dental Services?

Preventative Services / Restorative Services / Restorative Services with
Additional Lab Costs*
  • Cleanings
  • Fluoride
  • Study Models
/
  • X-Rays
  • Exams
  • Sealants
/
  • Fillings
  • Extractions
  • Endo
/
  • Bridges
  • Crowns
  • Dentures
/
  • Space Maintainers

*There is no discount for dental laboratory services. All dental laboratory service costs are the responsibility of the patient and must be paid prior to the delivery of dental product.

What is not covered under the Sliding Fee Program?

  • Costs of IUD’s
  • Cost of eye glass frames and lenses (down payment of 50% prior at time of order and balance due on delivery)
  • Prescriptions/Injections/Vaccines
  • Charges accrued from outside laboratories, services and/or referrals

Does Quest Diagnostics participate in the sliding scale program?

Quest Diagnostics has a sliding scale program similar to ours. However, Quest Diagnostics may have different discounts and adjustments available for their services. For more information from Quest Diagnostics please call (231)7453124.

Income Levels for Eligibility

Family Size
(2016 Federal Poverty) / Sliding Scale A
(0% - 100%) / Sliding Scale B
(101% - 133%) / Sliding Scale C
(134% - 166%) / Sliding Scale D
(167% - 200%) / Self-Pay Patient
(201% and above)
1 / $0 to $11,880 / $11,881 to $15,800 / $15,801 to $19,840 / $19,841 to $23,760 / $23,761 and above
2 / $0 to $16,020 / $16,021 to $21,307 / $21,308 to $26,753 / $26,754 to $32,040 / $32,041 and above
3 / $0 to $20,160 / $20,161 to $26,813 / $26,814 to $33,667 / $33,668 to $40,320 / $40,321 and above
4 / $0 to $24,300 / $24,301 to $32,319 / $32,320 to $40,581 / $40,582 to $48,600 / $48,601 and above
5 / $0 to $28,440 / $28,441 to $37,825 / $37,826 to $47,495 / $47,496 to $56,880 / $56,881 and above
6 / $0 to $32,580 / $32,581 to $43,331 / $43,332 to $54,409 / $54,410 to $65,160 / $65,161 and above
For Each Additional Person Added / +$4,160 / +$5,533 / +$6,947 / +$8,320
Document: Sliding Scale Program 2016 - English / Page 1 of 1