Sliding Fee Scale

Step 1. Fill out the Sliding Fee Application, you must include all household members and sign your application.

Step 2. Provide proof of your income. Please provide the following documents for each member of your household (related and unrelated) over the age of 18, to show household income:

• Income Tax Return- A signed copy of the most recent tax return showing Adjusted Gross Income.
• Paycheck stubs- Most recent pay stubs(s) indicating gross pay (Most recent 30-day period of work).
• Agency Letter- A letter from the Social Security Administration, Veterans Administration or Social Service Agency (i.e., AFDC, Food Stamps, or WIC) indicating income level.
• Unemployment Verification- Paperwork from the Employment Securities Commission (ESC), proving unemployment status and the amount of unemployment compensation being received.
• Court Documents- Official documents citing child support or alimony as awarded by a judge accompanied by a statement of child support enforcement stating amount received.
  • In the situation when a patient seeks services and identifies themselves as being separated from their spouse, legal documentation such as a legal separation agreement or divorce filing will be requested from the patient; but not required if self-declared.
• Official Paperwork- Paperwork documenting retirement, disability, and SSI benefits.
• Employer Letter- For those not receiving an actual paycheck, a letter from the patient's employer detailing current gross income and frequency of pay periods may be accepted. Contact information must be provided so that the information can be verified. (Preferably on business letterhead).
• For patient with no job or other income source- A letter from an agency, friend, relative or past employer who knows the situation and is not living with the applicant. The letter must include the writer's name and address (phone number if available) as well as a current or recent date (i.e., not from 2003).
• Self-declaration- is acceptable if no other information can be provided, the self-attestation form is to be completed.
• Minors- Minors applying for SFDS may declare as a separate household when seeking services for reproductive health. To include but not limited to, STD testing, pregnancy, birth control, etc.

Step 3. Return your Sliding Fee Application along with the supporting documentation using one of the ways listed below:

• Drop off at any of our Community Health Center of Central Wyoming clinic
• Mail it to CHCCW Billing Department, 5000 Blackmore Road, Casper, WY 82609
• E-mail it to slide@chccw.org  
• Fax it to 307.233.6089
• Complete using our online form

Step 4. Patient notification of Qualification  Your application will be processed, and you will receive a letter or email (based on the answer to the question on the slide fee application) explaining whether you qualify based on your application. If additional documentation is needed, we will contact you by telephone, mail, or email. Please allow up to 10 days for processing your application after it is received.

If it is determined that you do not qualify for our sliding fee program you will be responsible for any accrued charges  If it is determined that you do qualify for our sliding fee program a credit will be given if you have overpaid for your clinic visit and have no other outstanding bills or past bad debt to CHCCW.

This information is STRICTLY CONFIDENTIAL, and your name will never be disclosed in any reports. Please complete this form, listing everyone in your household, and their annual income.

I, the undersigned, have completed this application for Sliding Fee eligibility and confirm that this information is true and correct, to the best of my knowledge. I further understand that should my economic situation change; I am solely responsible to report the change upon my next visit. All information I provided within this application, including my self-attestation statement is truthful, correct and is subject to confirmation by CHCCW. Any false statement or perceived attempt to deceive may result in a denial for sliding fee benefits and the balance associated with it would be my responsibility.