Fairfield Community Health Center never turns anyone away due to insurance status, employment status, or ability to pay for services. We offer a sliding fee scale to our patients who may benefit from it, including the uninsured.

If you think you would benefit from the sliding-fee scale, print the application above and bring it to our office, along with one of the following acceptable forms of income documentation:

Acceptable Income Documentation

• Pay Stubs – 1 month of gross household earnings

• Unemployment Benefits

• Workers Compensation Benefits

• Social Security Benefits – The patient must provide an award letter

• Child Support

• Alimony

• Tax Documents - W2’s, 1099, tax return (adjusted gross income)