Sliding Fee Scale FQHC

Sliding Fee Scale FQHC

2021 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 ( click on the Financial Application link to download )

  • Prior Years Tax form

  • Current W2 form

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

 

Any patient who has a financial hardship for medical or dental office visits, should speak with our Financial Counselor. As part of being an FQHC, SIU Center for Family Medicine will help you determine if you are eligible for our sliding fee program.

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.

                       2021 ANNUAL FEDERAL POVERTY LEVEL (FPL) GUIDELINES

FAMILY SIZE --

Members in  Household

  2021 FPL 

        Level 0

  100% or Less
 

      Level 1

  101%-138% 
 

      Level 2

  139%-150% 
 

      Level 3

  151%-175% 
 

      Level 4

  176%-200% 
 

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

1

$12,880

$12,880

$17,774

$19,320

$22,540

$25,760

2

$17,420

$17,420

$24,040

$$26,130

$30,485

$34,840

3

$21,960

$21,960

$30,305

$32,940

$38,430

$43,920

4

$26,500

$26,500

$36,570

$39,750

$46,375

$53,000

5

$31,040

$31,040

$42,835

$46,560

$54,320

$62,080

6

$5,580

$35,580

$49,100

$53,370

$62,265

$71,160

7

$40,120

$40,120

$55,366

$60,180

$70,210

$80,240

8

$44,660

$44,660

$61,631

$66,990

$78,155

$89,320

Each add'l family member
> 8

$4,540

$4,540

$4,540

$4,540

$4,540

$4,540


                                        Sliding Fee Scale

 

  Nominal Charge  

    FQHC Level

              0

 

  FQHC Level  

           1

 

  FQHC Level  

          2

 

  FQHC Level  

          3

 

  FQHC Level  

           4

MEDICAL/BEHAVIORAL     

 Click to download a copy 

            $5

         $10

         $15

         $20

         $25

DENTAL

 Click to download a copy

                        Please Refer to the Dental Document