Financial Assistance

Sliding Fee Discount Program

Siskiyou Community Health Center serves all patients regardless of ability to pay. Sliding fee discounts are offered with eligibility based on your household size and income.

To be considered for this program you need to complete our Eligibility Determination Application below, and submit acceptable proof of income for all adults in the household. If you do not supply adequate proof of income or you do not qualify based on the proof of income received, you will be responsible for the full charges.
Once your application is approved, it will be valid for one year, unless your financial situation changes. A new application and proof of income will be required after one year to continue on the slide program.

You will be expected to pay your portion of the visit, if any, at check-in.

Download Application (English)
Download Application (En Español)

Household Member Guidelines:

  • Includes you, your spouse, your children (anyone you claim as a dependent on your federal tax return), your live-in partner (if you have children together), and anyone else you include on your federal tax return, even if they do not live with you. A copy of your federal tax return will be required as proof of dependents if individuals, other than your spouse and children under 18, are indicated.

Acceptable Proof of Income:

  • Currently Employed – A copy of your most current month’s worth of pay stubs. If you are paid monthly, you will need to bring 2 month’s worth.

  • Self Employed – A copy of your most recent federal tax return, including the signature page.

  • Unemployed – Documentation that indicates your weekly benefit amount before taxes.

  • Social Security Disability or Social Security Retirement Letter – An SSA-1099 will not be accepted.

  • Worker’s Compensation Letter

  • Child or Alimony Support – A copy of the court order showing the monthly amount received.

  • No Income – If an adult in the household does not work or is not receiving any income, an Unable to Provide Documentation of Income form will need to be completed.

Frequently Asked Questions:

The Slide Program at Siskiyou Community Health Center is a federal program that allows us to offer discounts on our services to patients who may not have the ability to pay in full.

Eligibility is based on your household size and income.

The Slide Program is available to all of our patients, even those who have insurance including Medicare, Oregon Health Plan and/or private insurance. Applying for our Slide Program has no impact on your current insurance coverage.

The household includes you, your spouse, your children (anyone you claim as a dependent on your federal tax return), your live-in partner (if you have children together), and anyone else you include on your federal tax return, even if they do not live with you. A copy of your federal tax return will be required as proof of dependents if individuals, other than your spouse and children under 18, are indicated.

Our slide discounts apply to all services at Siskiyou Community Health Center, including in-office procedures, dental care, pharmacy, and in-house labs.

While your insurance may cover many of the services you receive, the Slide Program may be able to assist with any balance due beyond insurance such as copays, coinsurance or deductible amounts. It may also help reduce the cost of services your insurance may not cover such as labs, pharmacy or dental care.

You will need to complete our Eligibility Determination Application (middle of page under Sliding Fee Discount Program) and submit proof of income for every adult listed in the household. Once your application is approved, it will be valid for one year, unless your financial situation changes. A new application and proof of income will be required after one year to continue to be considered for the slide program.

LINKS

 
Patient Forms
How Do I Establish Care?
Frequently Asked Questions
Patient Rights & Responsibilities
HIPAA (Privacy Practices)