School-Based Health Alliance
SUBJECT: Sliding Fee Program
POLICY: Patients with income below the Federal poverty level are expected to pay for medical services received at Rainelle Medical Center, Inc. on a sliding fee basis.
DISCUSSION: Patients indicating they are unable to pay for medical services and or medications will first be directed to the County Department of Health and Human Services to apply for a Medicaid card.
On receipt of a letter of denial of eligibility of Medicaid coverage, the patient may then apply for the SBHC’s sliding fee program.
Patients applying for the SBHC’s sliding fee program are expected to provide several types of information as required by the sponsoring agency, such as:
A. Completion of Income Verification Form – Form S/F-1, which includes family size, head of household, spouse, legal dependents, etc.
B. Birth dates, Social Security Numbers as appropriate.
C. Proof of Income, validated by tax returns, 1099 forms, W-2’s, unemployment receipts, and or check stubs.
D. Those claiming NO INCOME, which will be very rare, must sign a statement swearing to the fact of no income.
E. Sign a Statement of Understanding – Form S/F-2.
Using the above information the patient will be classified into an expected to pay category determined from the Federal Poverty guidelines.
A patient unable to pay their porting of the sliding fee is expected to make payment arrangements in the billing office.
Sliding Fee documentations are good for 1 year and must be renewed. The renewal process includes obtaining a new letter of denial from the Medicaid program and reevaluation of income as indicated above.
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