Sliding Fee Discount Program

It is the policy of Siskiyou Community Health Center to provide quality health care to our patients.  We offer a sliding discount program for many of our preventive and essential services so you can receive this quality care even when you may not have the ability to pay full fees.  Our sliding discount program is based solely on family size and income in relation to the Federal Poverty Level.

To be considered for this program you need to complete an application and submit acceptable proof of income for all adults in the household.  If you do not supply adequate proof of income or you do not qualify based on the proof of income received, you will be responsible for the full charges.

Once you have qualified for the program you will be eligible until March 31st.  A new application and proof of income is required each April 1st or your first visit after this date.

You will be expected to pay your portion of the visit at check in for each visit.

Household Member Guidelines:

    • Includes yourself, spouse and dependents under the age of 19.
    • Significant others are not considered household members.
    • Any other adult living in the home, even if they are related, would not be included in the household count. They would need to complete a separate application.

Acceptable Proof of Income:

    • Pay Stubs: A full month’s worth of Pay Stubs for the most current month (2 months if paid monthly). Must include employer name, pay period and gross wages.
    • Letter of Determination: Social Security, Disability, Unemployment (must show gross weekly amount), Child support/alimony, Worker’s Compensation.
    • Self Employed applicants: Copy of your most recent Federal Tax Return (1040) with signature page. (Do not submit W-2s or 1099s).
    • Students: Financial Aid Award Letter

Services Included In The Slide Discount Program

Not all services are eligible for the slide discount. Below are services included in the slide. You will be 100% responsible for the balance due on services not included.

Dental

    • Exams
    • X-rays
    • Prophy
    • Fluoride
    • Sealants
    • Periodontal Scaling/Maintenance
    • Debridement

Medical/Behavioral Health Services

    • Office Visits
    • Preventive Exams
    • Medically necessary in-office procedures
    • EKG
    • Breathing Tests
    • Nursing Home visits
    • Hospital visits by SCHC providers
    • Labs
    • Behavioral health office visits
    • OB Care

NOTE: Drug Screens, Vaccines, Lesion Removal/Destruction, Sports Physicals, Medications/Supplies, Tooth Extractions and Fillings are among the NON-COVERED SERVICES