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Income-Base Sliding Fee Scale

What is the Income-Based Sliding Fee Scale?

2024 Sliding Fee Income Chart

Sliding Fee Application

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)

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