SLIDING FEE SCALE DISCOUNT PROGRAM

Welcome to the Loudoun Community Health Center!

The cost of your visit is based on the services provided and your eligibility for our Sliding Fee Scale Discount Program. Your eligibility is based on total family income and family unit size.

Sliding Fee Scale Discount Program: Based upon family unit size and total household income level, you may be eligible for a discount off our regular fees.

A family unit may include mother, father, children, partners/significant others, siblings, stepchildren, parents, and/or step-parents.

Household income includes income from all jobs held by anyone living in the household and contributing to paying for household expenses, including all employed family members’ salaries, child support, unemployment compensation, disability payment and Social Security benefits.

Photo identification is required to ensure patient identification.

You must inform the health center of any insurance coverage. If you have insurance, this will not affect your eligibility, but your insurance must be billed before the sliding fee discount is applied.

To continue to participate in this discount program, you must reapply every 12 months. You must inform the health center immediately of any change in family unit income and/or size. You may request to reapply at any time if your household income changes.

Verification of Income: To qualify for our discount program you must provide supporting documentation. Applications must include all family unit members and family unit income. We will be contacting your employer to verify your income.

• Previous month's pay stubs (1-4 pay stubs depending upon how often you are paid)
• If you are paid in cash, a letter from your employer on letterhead with contact information (including address and telephone) stating earnings over the previous month.
• W2 or 1099
• Social Security award letter or copy of check
• Disability award letter or copy of check
• Unemployment award letter or copy of check
• Child support verification (copy of check, court papers with support amount or notarized letter from parent making payment)
• If your paychecks are automatically deposited into your bank account, please furnish a copy of your bank statement with the deposit amount.