Sliding Fee Scales Notice to patients: Community Health Centers of the Rutland Region serves all patients regardless of income or insurance status. Discounts for essential services provided by CHCRR are offered on a sliding fee scale basis adjusted for family size and income. Front desk personnel can assist you in applying, or you may apply directly by calling the clinic and asking for the patient outreach coordinator. Medical Sliding Fee Scale 25% Discount If your income falls between Family Size Federal Poverty Level 1 $20,503—$24,120 2 $27,609—$32,480 3 $34,715—$40,840 4 $41,821—$49,200 5 $48,927—$57,560 6 $56,033—$65,920 7 $63,139—$74,280 8 $70,245—$82,640 Greater of $20 Nominal Fee or 75% collected at time of service 50% Discount If your income falls between Family Size Federal Poverty Level 1 $16,282—$20,502 2 $21,925—$27,608 3 $27,568—$34,714 4 $33,211—$41,820 5 $38,854—$48,926 6 $44,497—$56,032 7 $50,140—$63,138 8 $55,783—$70,244 Greater of $20 Nominal Fee or 50% collected at time of service 75%Discount If your income falls between Family Size Federal Poverty Level 1 $12,061—$16,281 2 $16,241—$21,924 3 $20,421—$27,567 4 $24,601—$33,210 5 $28,781—$38,853 6 $32,961—$44,496 7 $37,141—$50,139 8 $41,321—$55,782 Greater of $20 Nominal Fee or 25% collected at time of service 100%Discount If your income falls between Family Size Federal Poverty Level 1 $0—$12,060 2 $0—$16,240 3 $0—$20,420 4 $0—$24,600 5 $0—$28780 6 $0—$32,960 7 $0—$37,140 8 $0—$41,320 $20 Nominal Fee to be collected at time of service Add: $4,180 for each additional family member over 8. Medical Sliding Fee Application Dental Sliding Fee Scale 25% Discount If your income falls between Family Size Federal Poverty Level 1 $20,503—$24,120 2 $27,609—$32,480 3 $34,715—$40,840 4 $41,821—$49,200 5 $48,927—$57,560 6 $56,033—$65,920 7 $63,139—$74,280 8 $70,245—$82,640 25% of rendered service fee. Lab fees additional cost to patient 50% Discount If your income falls between Family Size Federal Poverty Level 1 $16,282—$20,502 2 $21,925—$27,608 3 $27,568—$34,714 4 $33,211—$41,820 5 $38,854—$48,926 6 $44,497—$56,032 7 $50,140—$63,138 8 $55,783—$70,244 50% of rendered service fee. Lab fees additional cost to patient 75%Discount If your income falls between Family Size Federal Poverty Level 1 $12,061—$16,281 2 $16,241—$21,924 3 $20,421—$27,567 4 $24,601—$33,210 5 $28,781—$38,853 6 $32,961—$44,496 7 $37,141—$50,139 8 $41,321—$55,782 Greater of $25 nominal. Lab fees additional cost to patient. 100%Discount If your income falls between Family Size Federal Poverty Level 1 $0—$12,060 2 $0—$16,240 3 $0—$20,420 4 $0—$24,600 5 $0—$28780 6 $0—$32,960 7 $0—$37,140 8 $0—$41,320 $25 Nominal Fee to be collected at time of service. Lab fees additional cost to patient. Add: $4,180 for each additional family member over 8. Dental Sliding Fee Application Applying for Sliding Fee When you come for your appointment to apply for sliding fee scales, please bring the following information with you: Birth Certificate Driver’s license with your picture on it or another photo ID showing your current address Proof of Residency (postmarked envelope, postcard or envelope, driver’s license issued within the last 6 months, utility bill, lease/rent receipt, property tax records) Proof of income including documentation for all wages earned (pay stubs for 4 consecutive pay periods or your tax return from the previous year), social security, worker’s comp, veteran’s benefits, military pay, child support/alimony, income from rent and interest/dividends from bank accounts, pensions and annuities. Medical Sliding Fee Application Dental Sliding Fee Application
