Sliding Fee Schedule

Kids Health Alliance Discounted/Sliding Fee Policy

 

Policy:

As an accredited National Health Service Corps site, it is the policy of Kids Health Alliance to provide essential medical services to all patients, regardless of the patient’s ability to pay. Discounts are offered to those who qualify based upon family/household size and annual income. A sliding fee schedule is used to calculate the basic discount and is updated each year using the Federal Poverty Guidelines. Once the application is approved, the discount will be honored for six months, after which the patient must reapply.

Discount Application Process

To apply for our Sliding Fee Schedule, the patient must provide necessary documentation along with a completed application. The required documentation includes proof of:

– Family Size
– Household Income

The discount will apply to all services received at this clinic, but not those services purchased from outside, including reference laboratory testing, drugs, and x-ray interpretation by a consulting radiologist, and other such services. This form must be completed every 6 months, or if your financial situation changes.

NOTE: To comply with federal regulations, in order to give you a discount on our medical services, it is necessary for us to ask some personal questions. Your answers will be kept on file and in strict confidence.

Your yearly income tax return, a copy of your W-2 form, last month’s paycheck stubs, copies of your social security checks, or other checks you may receive will be sufficient proof. Your annual income and your family size will be used to calculate your discount.

Download Discounted/Sliding Fee Application [PDF]-English

Download Discounted/Sliding Fee Application-Spanish