It is policy of Five Rivers Health Centers to provide primary health care services to patients in need regardless of ability to pay. Discounts are offered to members of households with a combined income of 200% and below of the Federal Poverty Level. To determine the percentage for which you qualify, please complete the following information and return to the front desk.
List all household members below:
Supporting documentation is required before Sliding Fee Scale Discount can be approved and approved discounts will be valid for up to twelve (12) months.Acceptable forms include: copies of 2 recent checks/stubs, previous year W-2, previous year tax return, public assistance or social security check/stub or letter of Award, Medical Assistance or Dept. of Social Services Certification Letter, proof of Governmental Assistance, employer verification letter, or proof of zero income (letter of support that has been completed by the individual providingsaid support or a signed self-attestation).
1) That the family size and income information listed is correct.2) Documentation supporting my family’s financial position is required before my discount can be approved, and that I must provide this information within thirty (30) days of the completion of this form.3) I must update this information if my situation changes.4) A new application must be completed at least every twelve (12) months.5) I have received information explaining the program and I understand and agree to abide by the terms.6) The discount program will only apply to services received at Five Rivers Health Centers. The sliding fee discount amount may vary depending on the services received.7) The following services or equipment are not covered in this discount program. a. All services and equipment received or purchased outside of this clinic including i. Reference laboratory testing ii. Drugs iii. X-ray interpretation by a consulting radiologist iv. Other such services.8) If I am a self-pay patient, I must pay a minimum of $20 prior to receiving any health care services.9) If an unpaid balance exists on my account after applying my discount percentage, I agree to make payment arrangements and honor the terms. If I am unable to make a payment in any given month, I must contact the Billing Office prior to the due date to discuss my need to modify my payment arrangement.10) If I am unable to make a payment, I will contact Five Rivers Health Center’s Billing Department at (937)734-6830.
I choose not to complete the Sliding Fee Application at this time. I am waiving my right to any discount for which I may otherwise be entitled. I understand that I will be responsible for full payment of all charges at the time of service.