Estimate Discounts

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Estimate Your Service Discount

This health center serves all patients regardless of ability to pay. Discounts for essential services are offered based on family size and income. For more information, call us at (317) 291-7422.
How many family members live in your household? *
Family is defined as: a group of two people or more (one of whom is the householder) related by birth, marriage, or adoption and residing in the same household; all such people are considered members of one family.
Family of 1: What is your family's annual household income? *

$0 - $13,590.00 $13,590.01 - $16,988.00 $16,988.01 - $20,385.00 $20,385.01 - $23,783.00 $23,783.01 - $27,180.00 $27,180.01 +
Family of 2: What is your family's annual household income? *

$0 - $18,310.00 $18,310.01 - $22,888.00 $22,888.01 - $27,465.00 $27,465.01 - $32,043.00 $32,043.01 - $36,620.00 $32,620.01 +
Family of 3: What is your family's annual household income? *

$0 - $23,030.00 $23,030.01 - $28,788.00 $28,788.01 - $34,545.00 $34,545.01 - $40,303.00 $40,303.01 - $46,060.00 $46,060.01 +
Family of 4: What is your family's annual household income? *

$0 - $27,750.00 $27,750.01 - $34,688.00 $34,688.01 - $41,625.00 $41,625.01 - $48,563.00 $48,563.01 - $55,500.00 $55,500.01 +
Family of 5: What is your family's annual household income? *

$0 - $32,470.00 $32,470.01 - $40,588.00 $40,588.01 - $48,705.00 $48,705.01 - $56,823.00 $56,823.01 - $64,940.00 $64,940.01 +
Family of 6: What is your family's annual household income? *

$0 - $37,190.00 $37,190.01 - $46,488.00 $46,488.01 - $55,785.00 $55,785.01 - $65,083.00 $65,083.01 - $74,380.00 $74,380.01 +
Family of 7: What is your family's annual household income? *

$0 - $41,910.00 $41,910.01 - $52,388.00 $52,388.01 - $62,865.00 $62,865.01 - $73,343.00 $73,343.01 - $83,820.00 $83,820.01 +
Family of 8: What is your family's annual household income? *

$0 - $46,630.00 $46,630.01 - $58,288.00 $58,288.01 - $69,945.00 $69,945.01 - $81,603.00 $81,603.01 - $93,260.00 $93,260.01 +
What is your family's household income? *
Please provide your best estimate.
People Above 8
Class A
Class B
Class C
Class D
Class E
Class F
Class
Cost Estimate
Please complete the questions above to see your cost estimate.
Level A

Based on your household size and income level, you will be asked the pay the following amounts for your visit:

Flat Fee: $10.00

This is the only fee you will be asked to pay for services during your visit.
Level B

Based on your household size and income level, you will be asked the pay the following amounts for your visit:

Nominal Fee: $20.00
Service Cost: 20%

You will receive an 80% discount for the services you receive during your visit.
Level C

Based on your household size and income level, you will be asked the pay the following amounts for your visit:

Nominal Fee: $30.00
Service Cost: 40%

You will receive an 60% discount for the services you receive during your visit.
Level D

Based on your household size and income level, you will be asked the pay the following amounts for your visit:

Nominal Fee: $40.00
Service Cost: 60%

You will receive an 40% discount for the services you receive during your visit.
Level E

Based on your household size and income level, you will be asked the pay the following amounts for your visit:

Nominal Fee: $50.00
Service Cost: 80%

You will receive an 20% discount for the services you receive during your visit.
Level F

Based on your household size and income level, you will be asked the pay the following amounts for your visit:

Nominal Fee: $75.00
Service Cost: 100%

You be asked to pay for the cost of the services you receive during your visit.
You qualify for our sliding fee discount program! Would you like to apply for the program online before your visit?

Yes No
Great! We will walk you through the steps of submitting the necessary information. Click the Next button below to get started.

Sliding Fee Discount Program Application

Please complete the following form to apply for the sliding fee discount program.
Name *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Email Address *
example@example.com
Date of Birth *

Month Day Year
Date
Have you already scheduled an appointment? *

Yes No
When is your appointment? *
Necessary Documents

The below is a general list of items that you may need during the application process. If you are unsure whether or not an item applies to your application, please call a financial counselor by calling 317-291-7422. You can upload the documents in advance of your appointment using this page.
ID Verification

Valid state-issued or Foreign photo operator's license or ID card Valid US or Foreign Passport I will bring this to my appointment
ID Verification Upload

Cancel of
Proof of Residence

Mortgage or Current lease Utility bill within last 30 days Current homeless shelter residency verification
Proof of Residence Upload

Cancel of
Proof of Income

Proof of income 5 most recent pay stubs or statement from employer on Company or Shalom letterhead with current gross income. Past years' annual tax returns (Self-employed only) Social Security or SSI/SSDI award letter (Call 1.800.772.1213 for replacement) Verification of pension or retirement benefits
Proof of Income Upload

Cancel of
Proof of Unemployment

Current statement from INET (WorkOne) if unemployed Statement of support of person(s) providing room and board with his/her name, address and what is being provided. Current trustee assistance - poor relief award letter
Proof of Unemployment Upload

Cancel of
Family Composition

Proof of dependent (s) birth certificate (s) Verification of enrollment for 18 and older student Tax records with dependent (s) listed Court-ordered guardianship or custody papers Divorce decree If spouse has moved out of the home, proof of spouses current address
Family Composition Upload

Cancel of
Other Documents

Copy of Medicaid/HIP award or denial letter Verification of HPE/PE application (if applicable) Proof of Medicare (including Part D) coverage Public Assistance (Excludes Food Stamps and Housing subsidies) Child Support Last three months of complete bank statements for all accounts Verification of student loans or grants (Proof of student enrollment) Verification of any other income
Other Documents Upload

Cancel of
Should be Empty: