CHC offers a Sliding-Fee Scale Financial Assistance Program. Eligible patients have household incomes at or below 200% of poverty. Patients enrolled in Medicaid, Medicare and with high deductible plans are also eligible for assistance. The Sliding-Fee Scale Financial Assistance Program can be used for all CHC programs and services. Download the Sliding-Fee Scale Application. The application is available in seven different languages, which can be found here.
What counts toward total household income?
Total household income is the total combined income of all household members. This includes money from:
- Self-employment (net income)
- Pensions, dividends, interest
- Social Security or unemployment benefits
- Stipends or any other monetary income received by members of the household
Which documents can I use to verify my income?
There are many documents we can accept to verify your household income when applying for our Sliding-Fee Scale. Some of the most common are:
- 2 consecutive paystubs from the last 30 days
- Social Security, disability or pension benefits statements
- IRS Form W-2 or 1099
- FAFSA form
- Most recently filed tax return
- Unemployment benefits statement
If you have no income, you may submit a written self-declaration form detailing how you support yourself financially, but you will only be eligible for benefits for 90 days. Remember, eligibility for our Sliding-Fee Scale is based on the total household income; therefore documents will be required for each person. If you have questions about whether you have the required documentation to verify your income, please call us before you come to apply.
Who is considered to be a household member?
We generally base the household members on tax household. Roommates who share mutual living expenses are not considered to be members of the same household.
If my Sliding-Fee Scale application is approved, how long will my benefits last?
Most patients will be enrolled into the Sliding-Fee Scale Program for one calendar year; after one year you may reapply with updated income verification documents. Those applying using a self-declaration of income or unemployment benefits statement will only be eligible for 90 days. Patients living outside Chittenden County are eligible to use their Sliding-Fee discounts for urgent dental care for 14 days. If your housing situation or income changes, your benefits may be affected. Please contact us for more information.
For questions and more information, please contact Patient Support Services at 802-264-8124 or firstname.lastname@example.org