Get the free Sliding Fee Scale Discount Application

This document is an application for the sliding fee scale discount offered by the Knox County Community Health Center (KCCHC). It allows patients to access essential medical, mental health, behavioral health, and dental services at reduced costs based on their household income and size. The form collects personal and financial information from patients to determine eligibility for the discount.

How to fill out sliding fee scale discount

How to fill out sliding fee scale discount

1. Gather your financial documentation, including income statements and household size.
2. Obtain the sliding fee scale application form from the relevant healthcare provider or organization.
3. Fill out the form with your personal information, including your name, address, and contact information.
4. Provide accurate income information for all members of your household, specifying the type of income received.
5. Indicate your household size, including all individuals living with you.
6. Attach any required documentation, such as pay stubs, tax returns, or benefits statements, that prove your income.
7. Review the completed application for accuracy before submission.
8. Submit the form along with your documentation to the appropriate office or online portal for review.

Who needs sliding fee scale discount?

1. Individuals or families with low income seeking affordable healthcare services.
2. Uninsured or underinsured patients looking for a reduced fee to access medical care.
3. Those experiencing financial hardship due to job loss, medical expenses, or other circumstances.
4. Students, seniors, or individuals on fixed incomes needing assistance with healthcare costs.

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What is sliding fee scale discount?

A sliding fee scale discount is a pricing structure that adjusts the fees for services based on the income and financial situation of the individual, allowing lower-income patients to pay less for medical and health services.

Who is required to file sliding fee scale discount?

Healthcare providers and organizations that offer services on a sliding fee scale, particularly those receiving federal funding such as community health centers, are required to file for sliding fee scale discounts.

How to fill out sliding fee scale discount?

To fill out a sliding fee scale discount, individuals typically need to provide information regarding their income, household size, and any relevant documentation to verify their financial status. This may include recent tax returns, pay stubs, or statements of income.

What is the purpose of sliding fee scale discount?

The purpose of a sliding fee scale discount is to make healthcare services more affordable and accessible to individuals and families with limited financial resources, ensuring that cost is not a barrier to receiving necessary medical care.

What information must be reported on sliding fee scale discount?

Information that must be reported on a sliding fee scale discount includes the patient’s income, family size, insurance status, and any other relevant financial information that helps determine the appropriate fee level.