Sliding Fee Schedule
In order to ensure that primary health care is made reasonably available to the people
of this area without regard to ability to pay, a Sliding Fee based on family size and
income is offered to established SCRFHC patients and their families.
- Using the Table below, find your family size down the left column
- Next, find your annual income range on that same line
- Last, follow the income range column upward to the point that tells you whether you might pay a nominal fee or a designated percentage of the charges.
Note: This is primarily an estimate that should provide enough information to determine whether you want to submit an application or not.
Individuals and families must complete the initial application for approval. The application and all required supporting documents will be reviewed and a decision made regarding the level of adjustment to be assigned. In addition, all participants in the Sliding Fee program must re-apply annually with current proof of income
What will I need to submit my application?
- Current Proof of Income: Last year’s Tax return, pay stubs x 4 weeks, unemployment benefit statement or Social Security 1099 or benefit notice.
- Fully completed Application, including family size and all information required.
If you are interested in applying for the Sliding Fee program, please email us at firstname.lastname@example.org
If you would like to download the application, please click here.
Outside labs may also offer a sliding fee option but the tests would most likely need to be collected here at SCRFHC to be considered for eligibility.
Sliding Fee Chart
The Sliding Fee schedule changes annually in accordance with the Department of Health and Human Services poverty guidelines. The St. Croix Regional Family Health
Center Board of Directors may also amend it. Sliding Fee cannot be applied to the cost of birth control measures.