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Serving our Communities since 1983

Serving our Communities since 1983

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Sliding Fee Discount Eligibility Determination Form PDF Print E-mail

 

If your income is at or below the federal poverty guidelines, you may qualify for a discount on the cost of your medical care You must provide us with documentation of your income. This can include:

● Most recent paycheck stub ● Most recent welfare benefit statement ● Most recent food stamp benefit statement

● Most recent unemployment or workers compensation benefit statement ● Most recent tax return ● Any other document that will prove how much income you receive.

If you do not receive any income, you must sign a statement explaining how you are being supported.

If you do not provide proof of your income at the time of your visit, you will be charged for the full cost of your medical care. Your proof of income statement will be valid for 1 year. After that time, new proof of your income will be required.

Depending on your income, you may be eligible to receive up to a 75% discount on the cost of your medical care or be charged with a nominal fee. Income guidelines are set by the federal government, not The Bay Clinic, Inc. If you are referred to another medical provider or facility for additional lab tests, x-rays or treatment, you will receive a separate bill from that facility, and will be responsible for the full cost of those services. Your Bay Clinic, Inc. medical provider may refer you to additional services because he or she may feel that it is an important part of your medical care. The Bay Clinic, Inc. will not pay for or provide discounts for any referred services. Occasionally, Bay Clinic, Inc. receives grants to help pay for referred services such as breast and and cervical cancer screenings, or chest x-rays. Please ask your nurse if you qualify for this support. 

If you have any questions about sliding fee discounts, please speak to a Patient Services Representative. If they are unable to answer your question(s), you will be referred to someone who can.

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