Sliding Fee Discount Program
Accessible care, regardless of income.
FAQ
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What are the benefits of enrolling in the program?
You may be eligible to receive medical, dental, and mental health services at discounted rates.
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How do you enroll?
- Complete the Sliding Fee Enrollment Form.
- Provide the completed form to the Patient Service Representative.
- If eligible, you will be asked to submit income documentation and complete the Income Verification Form. One visit may be extended before documentation is received.
- Enrollment lasts six months. Changes in income or household size must be reported.
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Who qualifies?
- Eligibility is based on income, family size, and insurance status.
- Most programs require income at or below 200% of the Federal Poverty Level.
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What documents are required?
- Proof of income (pay stubs, tax returns, employer letter).
- Valid photo identification.
- Household size information.
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How long is the sliding fee valid?
Six (6) months, with renewal required.
2026 SLIDING FEE DISCOUNT – AFFORDABLE MEDICAL AND DENTAL SERVICES
| % of Income Poverty | A (0–100%) |
B 101–133% |
C 134–150% |
D 151–170% |
E 171–185% |
F 186–200% |
G (201%+) |
|---|---|---|---|---|---|---|---|
| Family Size | |||||||
| 1 | $0–15,960 | $15,961–21,227 | $21,228–23,940 | $23,941–27,132 | $27,133–29,526 | $29,527–31,920 | $31,921+ |
| 2 | $0–21,640 | $21,641–28,781 | $28,782–32,460 | $32,461–36,788 | $36,789–40,034 | $40,035–43,280 | $43,281+ |
| 3 | $0–27,320 | $27,321–36,336 | $36,337–40,980 | $40,981–46,444 | $46,445–50,542 | $50,543–54,640 | $54,641+ |
| 4 | $0–33,000 | $33,001–43,890 | $43,891–49,500 | $49,501–56,100 | $56,101–61,050 | $61,051–66,000 | $66,001+ |
| 5 | $0–38,680 | $38,681–51,444 | $51,445–58,020 | $58,021–65,756 | $65,757–71,558 | $71,559–77,360 | $77,361+ |
| 6 | $0–44,360 | $44,361–58,999 | $59,000–66,540 | $66,541–75,412 | $75,413–82,066 | $82,067–88,720 | $88,721+ |
| 7 | $0–50,040 | $50,041–66,553 | $66,554–75,060 | $75,061–85,068 | $85,069–92,574 | $92,575–100,080 | $100,081+ |
| 8 | $0–55,720 | $55,721–74,108 | $74,109–83,580 | $83,581–94,724 | $94,725–103,082 | $103,083–111,440 | $111,441+ |
| Discount | 100% | 73% | 66% | 49% | 29% | 14% | 0% |
2026 SLIDING FEE DISCOUNT – URGENT CARE SERVICES
| Service Type | A | B | C | D | E | F | G |
|---|---|---|---|---|---|---|---|
| Office Visit | $0 | $67 | $85 | $127 | $177 | $215 | $250 |
| Nutrition Visit | $0 | $49 | $61 | $92 | $128 | $155 | $180 |
| Dental | |||||||
| Limited Oral Evaluation (D0140) | $0 | $15 | $19 | $29 | $40 | $49 | $57 |
| Detailed Oral Evaluation (D0120/D0150) | $0 | $21 | $27 | $40 | $55 | $67 | $78 |
| Extensive Oral Evaluation (D0160) | $0 | $37 | $47 | $70 | $98 | $119 | $138 |
| Comprehensive Periodontal Eval (D0180) | $0 | $17 | $21 | $32 | $45 | $54 | $63 |
| Prophylaxis – Adult (D1110) | $0 | $18 | $22 | $34 | $47 | $57 | $66 |
| Prophylaxis – Child (D1120) | $0 | $14 | $17 | $26 | $36 | $44 | $51 |
| Topical Fluoride (D1206) | $0 | $12 | $15 | $23 | $32 | $39 | $45 |
| Sealant – per tooth (D1351) | $0 | $11 | $13 | $20 | $28 | $34 | $39 |
* Extensive dental procedures may require additional deposits.
- Add $5,500 for each family member over eight.
- Valid photo ID required.
- Proof of income required.
- No documentation = full fee.
- Income above 200% FPL charged full fee.
- Services provided regardless of ability to pay.
- Laboratory and ancillary charges not included.
- Dental visits may include multiple services.
