Sliding Fee Discount Program
Siskiyou Community Health Center serves all patients regardless of ability to pay. Sliding fee discounts are offered depending upon family size and income.
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.
- 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. (Some exceptions do apply)
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