Sliding Fee Scale FQHC

2019 SLIDING FEE SCALE for FINANCIAL ASSISTANCE

All patients who do not have coverage for medical or dental insurance are eligible for financial assistance based on their income. To see if you qualify all patients are asked to call the office and come to the clinic, and speak to our Financial Counselors. All patients will need to fill out and provide:

  • SIU Center for Family Medicine Financial Application

  • Prior Years Tax form

  • Current W2 form

  • A letter from a person who is providing financial support if applicant has no income

The sliding scale fee is applicable to all office visit. Your co-pay is expected at the time of service. Any patient who continues to have financial hardship with payments for medical office visits, should speak with our Financial Counselor and discuss further assistance with a payment plan method.

Local specialist and hospitals are also capable of extending financial assistance for their services. Please contact them individually prior to or at the time of service.

Depending on the Family Size and the annual income, patient(s) will be placed into five categories of discounted care as listed below.

 

 

SLIDING FEE SCALE

 

 Nominal Charge

FQHC Level 1

FQHC Level 2

FQHC Level 3

FQHC Level 4

MEDICAL/BEHAVIORAL CARE

$5

$10

$15

$20

$25

DENTAL CARE

 Download the PDF file for details


 

Federal Poverty Level (FPL)

 

2019
FPL

Less 100%
 

FQHC Level
0

101%-138%
 

FQHC Level 1

139%-150%
 

FQHC Level 2

151%-175%
 

FQHC Level 3

176%-200%
 

FQHC Level 4

FAMILY SIZE --
Members in Household

Annual income displayed is highest possible in each category in order to qualify

1

$12,490

$12,490

$17,236

$18,735

$21,858

$24,980

2

$16,910

$16,910

$23,336

$25,365

$29,593

$33,820

3

$21,330

$21,330

$29,435

$31,995

$37,328

$42,660

4

$25,750

$25,750

$35,535

$38,625

$45,063

$51,500

5

$30,170

$30,170

$41,635

$45,255

$52,798

$60,340

6

$34,590

$34,590

$47,734

$51,885

$60,533

$69,180

7

$39,010

$39,010

$53,834

$58,515

$68,268

$78,020

8

$43,430

$43,430

$59,933

$65,145

$76,003

$86,860

Each add'l family member
> 8

$4,420

$4,420

$6,100

$6,630

$7,735

$8,840