WFMC Sliding Scale Application
At WFMC Health we are dedicated to providing quality healthcare services, education, and guidance in promoting health and wellness to all patients regardless of language or financial barriers.
Purpose/Policy Statement
If you are uninsured and have a low income, you may qualify for a sliding fee for your medical services. This program is made available by WFMC Health to provide medical care for people who otherwise may be unable to see a doctor. We do not receive any government money to fund this program, therefore we may not be able to offer a discount to everyone who qualifies, and we reserve the right to discontinue the program at any time. You are expected to pay the discounted rate or minimum fee for services. If you cannot pay at the time of service, please make arrangements for payments.
The discount applies only to services provided by our clinic doctors; we may be able to help arrange a reduced fee for laboratory tests. You must make separate arrangements to pay for x-rays, ultrasounds, visits to specialist, or hospital care with those providers.
Eligibility Criteria
If your family has a total household income less than 200% of the federal poverty level you may qualify for a discount from our original fees. Income means your paycheck before deductions, pension, retirement, or social security income, cash child support, alimony, workers compensation payments, etc. from all sources in the family. All office visits are eligible for a sliding fee; this does not apply to routine physicals, prenatal care or medication and supplies, for these services have been set at a reasonable fixed price.
Criteria considered in determining eligibility for a sliding fee include, but are not limited to:
- The household’s gross income, based on total family members.
- The patient’s employment status and capacity for future earnings.
- Other living expenses & financial obligations.
- The family’s monthly out of pocket expenses for medical supplies and services.
Supporting documentation may include the following:
- One month income verification (prior month of date applying) in the form of pay stubs, bank deposits, etc.
- Social Security determination letters
- The prior year’s tax returns
- A “Statement of Sustainability” that indicates how persons with no income are meeting their day to day basic living needs.
There is a minimum fee of $35.00 for each doctor visit regardless of the discount you may qualify for. The amount of $35.00 is only a down payment towards your office visit. The remaining balance after discount is your responsibility and will be billed to you.
To apply, you must complete WFMC Health’s application for a sliding fee and return it within 30 days of the stamped date. Until this process is completed, you will be responsible for the full charges. The sliding fee is good for six months from the date of the application. To continue receiving a sliding fee you must re-apply and furnish proof of income.