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.
2025 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 | $0–15,650 | $15,651–20,815 | $20,816–23,475 | $23,476–26,605 | $26,606–28,953 | $28,954–31,300 | $31,301+ |
| 2 | $0–21,150 | $21,151–28,130 | $28,131–31,725 | $31,726–35,955 | $35,956–39,128 | $39,129–42,300 | $42,301+ |
| 3 | $0–26,650 | $26,651–35,445 | $35,446–39,975 | $39,976–45,305 | $45,306–49,303 | $49,304–53,300 | $53,301+ |
| 4 | $0–32,150 | $32,151–42,760 | $42,761–48,225 | $48,226–54,655 | $54,656–59,478 | $59,479–64,300 | $64,301+ |
| 5 | $0–37,650 | $37,651–50,075 | $50,076–56,475 | $56,476–64,005 | $64,006–69,653 | $69,654–75,300 | $75,301+ |
| 6 | $0–43,150 | $43,151–57,390 | $57,391–64,725 | $64,726–73,355 | $73,356–79,828 | $79,829–86,300 | $86,301+ |
| 7 | $0–48,650 | $48,651–64,705 | $64,706–72,975 | $72,976–82,705 | $82,706–90,003 | $90,004–97,300 | $97,301+ |
| 8 | $0–54,150 | $54,151–72,020 | $72,021–81,225 | $81,226–92,055 | $92,056–100,178 | $100,179–108,300 | $108,301+ |
| Discount | 100% | 73% | 66% | 49% | 29% | 14% | 0% |
2025 SLIDING FEE DISCOUNT – URGENT CARE SERVICES
| Service Type | A | B | C | D | E | F | G |
|---|---|---|---|---|---|---|---|
| Office Visit | $0 | $65 | $82 | $123 | $172 | $208 | $242 |
| Nutrition Visit | $0 | $49 | $61 | $92 | $128 | $155 | $180 |
| Limited Oral Evaluation (D0140) | $0 | $15 | $19 | $29 | $40 | $49 | $57 |
| Detailed Oral Evaluation (D0120) | $0 | $21 | $27 | $40 | $55 | $67 | $78 |
| Extensive Oral Evaluation (D0160) | $0 | $37 | $47 | $70 | $98 | $119 | $138 |
| Periodontal Evaluation (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.
