Sliding fee application forms

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About the sliding fee discount program

if you need help paying for health care expenses, we offer discounted fees based on your household size and income. For more information and to apply, meet with one of our eligibility specialists. Find a clinic near you to make an appointment.

If you qualify for our sliding fee discount program, the fees start at:

  • $20 for a medical appointment
  • $45 for a dental appointment

You will not be denied services if you are unable to pay. 

 

For your appointment with an eligibility specialist, please bring:

  • Proof of information regarding household size and identity information for all individuals contributing to household income.
  • Proof of 30 days gross income for every member of the household contributing to income. Specifically, all types of earned and unearned income.
  • Examples of proof of income include:
    • 1040 Federal Tax Form
    • pay stubs/wages and tips/gratuities/bonuses
    • back pay
    • military pay
    • self-employment, hobby income, compensation for personal services
    • income from IRA distributions, interest or annuities, dividends, capital gains, pension, rent
    • royalties and foreign income, alimony
    • Last two unemployment check stubs 
  • If you have no income, provide a letter of support or reference from an organization/individual and a signed statement of zero income. 
  • Additional documents may be required on a case-by-case basis.

Uninsured patients

We welcome patients who do not have insurance. We ask all uninsured patients to make an appointment with one of our eligibility specialists to learn if they qualify for health insurance through Washington Healthplanfinder, our sliding fee discount program, or other programs. You may be eligible for low-cost or no-cost insurance. One of our eligibility specialists can help you understand your health insurance options. Learn more about insurance assistance. To make an appointment with an eligibility specialist, find a clinic. 

Deposits

If you choose not to apply for insurance or the sliding fee discount, we ask for a deposit to cover the initial cost of your care.

  • $80 for medical
  • $90 for dental

You will not be denied services if you are unable to pay. 

Insured patients

We accept most insurance, including Washington Apple Health (Medicaid), Medicare, and private plans. Proof of insurance or payment is expected at the time of service, including co-pays.