G.A. Carmichael Family Health Center (GACFHC) provides access to health services to all individuals and families without regard for a person’s ability to pay. This is accomplished by adoption of a Sliding Fee Discount Schedule offering a range of discounts against charges for services we provide. Ability to pay is determined by a patient’s annual income and family size according to the most recent U.S. Department of Health & Human Services Federal Poverty Guidelines.
Sliding Fee Discount Schedule patients receive a discount of charges based on where they fall on a discount schedule based on the annual Federal Poverty Guidelines. Depending on household size and household income, patients are assigned a discount tier of the fees normally charged for a medical or dental visit, with a nominal fee of $25 (Medical) and $30 (Dental) for the 100% tier and below.
| Family Income per Poverty Guidelines | Sliding Fee Discount |
| 100% and below | Medical -Nominal Fee:$25 / Dental $30 |
| 100-133% | Medical -$45/ Dental $40 |
| >133-150% | Medical $60 / Dental $45 |
| >150-185% | Medical $70 / Dental $50 |
| >185-200% | Medical $75 / Dental $60 |
| Above 200% | No Discount |
Determining Sliding Fee Discount Schedule Eligibility
Income Documentation
Upon registration for health services, the patient completes income and household size information asked for on their registration form. The receptionist then tells the patient of the requirement to document their stated income. Pending confirmation of income, the patient is placed on the SFDS according to the information on his/her intake form. The initial visit is covered by acceptance of stated income and household size with the completion of the self-declaration form; but subsequent visits are charged at the Full Fee rate until the income verification is submitted. Full Fee charges continue until the patient’s income is satisfactorily documented and his/her position on the sliding fee discount schedule is confirmed. Although the discount is applied to current and future visits, it is not retroactive.
Information accepted for income verification includes:
- Check stub
- Letter from employer stating the (gross) income
- Copies of tax returns, or
- Letter from the institution documenting public benefits: Food Stamps, TANF, Social Security, VA Income
- Other acceptable documents – please see Patient Financial Services representative
Self-Declaration
There are occasions when a patient is unable to verify his/her income through an employer or other source. When these conditions exist, there are two tests that will permit consideration of a patient completing a “Self-Declaration” of their income using the Self-Declaration Form. The criteria that must be weighed when issuing a Self-Declaration are limited to:
- The patient works for cash and employer will not provide any wage documentation.
- The patient states that he/she has no income, is unemployed and does not receive any public benefits.
Standing Rule–At no time during intake, income verification; self-declaration; or failure to make the minimum payment is the patient refused services
- Income Recertification
Patients who are found eligible for the Sliding Fee Discount Schedule may be asked to re-verify their income at least annually and more often if established under Self-Declaration.
Patients will be asked routinely to update their basic demographics including home address, telephone number and any change in income or family size. However, this information is gathered to best assure the clinic is able to maintain contact with the patient; and to identify if there are circumstances that may impact on their access to care.
NOTE: The Sliding Fee Discount Schedule is applied uniformly, consistently, and equally for all eligible patients.