Sliding Fee Program
As a Community Health Center, we have the unique opportunity to offer our patients a discount on services based on family size and annual income. For questions or more information, please call (585) 637-3905 ext. 315.
In order to receive Family Assistance, an application must be completely filled out, signed and dated:
The First Section must include your name, current address, including city, state, zip and current phone number including area code. A cell phone number will be helpful, if we have to get in touch with you.
The Second Section must be filled out by listing all household income, both taxable and nontaxable for you, spouse and dependents. This income includes but is not limited to, Wages and Tips if applicable, Pensions, Annuities, Veteran Benefits, Social Security Benefits (net amount after deductions for Medicare), Alimony, Child Support, Workers Compensation, State Unemployment Insurance, Self‐Employment Income, Rental Income, Farm Income and Small Business Corporation Income.
The Third Section must include all family members living in your household and who you may claim as a dependent when filing your tax return, their dates of birth and any health insurance they have.
In addition to a completely filled out application, we require certain documentation to be attached to the application in order for it to be processed:
A copy of page 1 and 2 of the most recent federal tax return filed AND
If you are currently working, we need four (4) most current pay stubs that list your name, employer, pay period (weekly, bi‐weekly, monthly), gross wages hours worked, wage rate, etc.
If you get paid in cash, we need a signed letter from your employer stating your hourly wage rate, number of hours worked and the pay period covered.
If you are self‐employed or have farm income, we need a copy of the schedule “C” “Profit or Loss from Business” and/or “F” “Profit or Loss from Farming” that was filed with your tax return. If your application is submitted after June 30th of the current year, we will also need a written estimate of your anticipated net income for the current year.
If you have rental income, we need a copy of schedule “E” “Supplemental Income and Loss” that was filed with your tax return.
If you are a shareholder of a “small business corporation” and receive compensation and/or taxable income from this corporation, we need a copy of the “K‐l” and schedule “E” Supplemental Income and Loss that was filed with your tax return.
If your only source of income is Social Security Benefits and/or Pension Benefits and you do not file a tax return, we need a copy of the statement you receive at the beginning of the year stating what your monthly benefits will be. If you get your benefits directly deposited to your account, we will need a copy of the bank statement showing such deposits.
If you are receiving alimony and/or child support payments, we need a copy of the court document or a letter from who you are receiving these payments stating the amount paid and how often the payments are made and who the payments are for.
If you are unemployed and collect unemployment insurance, we need to have documentation from unemployment insurance as to what your benefits are, weekly rate and when they began.
If you have no income at all, we need a signed statement from you stating how you are being supported.
Upon receipt of the properly completed application and required documentation, your application will be processed.
Please call our Patient Engagement Department at 585‐637‐3905 ext. 315.