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, including discounts for pharmacy services provided by CHCRR or one of the contracted pharmacies, 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 & Behavioral Health Sliding Fee Scale 100% Discount $10 Nominal Fee to be collected at time of service If your income falls between Family Size Federal Poverty Level 1 $0—$12,140 2 $0—$16,460 3 $0—$20,780 4 $0—$25,100 5 $0—$29,420 6 $0—$33,740 7 $0—$38,060 8 $0—$42,380 For each additional person add $4,320 75% Discount Greater of $20 Nominal Fee or 25% of the charge to be collected at time of service If your income falls between Family Size Federal Poverty Level 1 $12,141—$16,389 2 $16,461—$22,221 3 $20,781—$28,053 4 $25,101—$33,885 5 $29,421—$39,717 6 $33,741—$45,549 7 $38,061—$51,381 8 $42,381—$57,213 For each additional person add $4,320 50%Discount Greater of $20 Nominal Fee or 50% of the charge to be collected at time of service If your income falls between Family Size Federal Poverty Level 1 $16,390—$20,638 2 $22,222—$27,982 3 $28,054—$35,326 4 $33,886—$42,670 5 $39,718—$50,014 6 $45,550—$57,358 7 $51,382—$64,702 8 $57,214—$72,046 For each additional person add $4,320 25%Discount Greater of $20 Nominal Fee or 75% of the charge collected at time of service If your income falls between Family Size Federal Poverty Level 1 $20,639—$24,280 2 $27,983—$32,920 3 $35,326—$41,560 4 $42,671—$50,200 5 $50,015—$58,840 6 $57,359—$67,480 7 $64,703—$76,120 8 $72,047—$84,760 For each additional person add $4,320 Medical & Behavioral Health Sliding Fee Application Pharmacy Sliding Fee Scale 100% Discount Acquisition cost + pharmacy dispensing fees + $2.50 admin fee If your income falls between Family Size Federal Poverty Level 1 $0—$12,140 2 $0—$16,460 3 $0—$20,780 4 $0—$25,100 5 $0—$29,420 6 $0—$33,740 7 $0—$38,060 8 $0—$42,380 For each additional person add $4,320 75% Discount Acquisition cost + pharmacy dispensing fees + $5.00 admin fee If your income falls between Family Size Federal Poverty Level 1 $12,141—$16,389 2 $16,461—$22,221 3 $20,781—$28,053 4 $25,101—$33,885 5 $29,421—$39,717 6 $33,741—$45,549 7 $38,061—$51,381 8 $42,381—$57,213 For each additional person add $4,320 50%Discount Acquisition cost + pharmacy dispensing fees + $7.50 admin fee If your income falls between Family Size Federal Poverty Level 1 $16,390—$20,638 2 $22,222—$27,982 3 $28,054—$35,326 4 $33,886—$42,670 5 $39,718—$50,014 6 $45,550—$57,358 7 $51,382—$64,702 8 $57,214—$72,046 For each additional person add $4,320 25%Discount Acquisition cost + pharmacy dispensing fees + $10.00 admin fee If your income falls between Family Size Federal Poverty Level 1 $20,639—$24,280 2 $27,983—$32,920 3 $35,326—$41,560 4 $42,671—$50,200 5 $50,015—$58,840 6 $57,359—$67,480 7 $64,703—$76,120 8 $72,047—$84,760 For each additional person add $4,320 Pharmacy Sliding Fee Application Dental Sliding Fee Scale 100% Discount $10 Nominal Fee collected at time of service. Lab fees additional cost to patient. If your income falls between Family Size Federal Poverty Level 1 $0—$12,140 2 $0—$16,460 3 $0—$20,780 4 $0—$25,100 5 $0—$29,420 6 $0—$33,740 7 $0—$38,060 8 $0—$42,380 For each additional person add $4,320 75% Discount Greater of $25 nominal or 25% collected at time of service. Lab fees additional cost to patient. If your income falls between Family Size Federal Poverty Level 1 $12,141—$16,389 2 $16,461—$22,221 3 $20,781—$28,053 4 $25,101—$33,885 5 $29,421—$39,717 6 $33,741—$45,549 7 $38,061—$51,381 8 $42,381—$57,213 For each additional person add $4,320 50%Discount Greater of $25 nominal or 50% collected at time of service. Lab fees additional cost to patient. If your income falls between Family Size Federal Poverty Level 1 $16,390—$20,638 2 $22,222—$27,982 3 $28,054—$35,326 4 $33,886—$42,670 5 $39,718—$50,014 6 $45,550—$57,358 7 $51,382—$64,702 8 $57,214—$72,046 For each additional person add $4,320 25%Discount Greater of $25 nominal or 75% collected at time of service. Lab fees additional cost to patient If your income falls between Family Size Federal Poverty Level 1 $20,639—$24,280 2 $27,983—$32,920 3 $35,326—$41,560 4 $42,671—$50,200 5 $50,015—$58,840 6 $57,359—$67,480 7 $64,703—$76,120 8 $72,047—$84,760 For each additional person add $4,320 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 & Behavioral Health Sliding Fee Application Pharmacy Sliding Fee Application Dental Sliding Fee Application
