Sliding Fee Scale Proof of Income:

In order to determine if a patient qualifies for the sliding fee scale, proof of income and household size must be presented to the patient representative during intake.  The best form of proof of income is your federal tax return (1040,1040A,or 1040EZ) or your food stamp eligibility statement because these documents provide all that is needed in one source.  However, the following items are acceptable forms of proof of income and family size.  Please bring at last one item from each of the two columns below. It may be necessary to bring more than one item in order to provide all the information needed to determine the patient’s eligibility for the slide scale.  The discount cannot be assigned until you have provided sufficient documentation to determine total household income and total household size which is the total number of individuals living under one roof.   

Income Household Size
  • Current Federal Tax Return (individual or joint)
  • W-2 Forms for each member of the household (cannot be used as only proof of income)
  • Pay stubs (4 if you get paid once per week, 2 if you get paid biweekly, and one if you only get paid once per month)
  • Employer Statement(must include a contact name and number)
  • Alimony Agreement
  • Child Support Agreement
  • Award Letter from the Veterans Administration
  • Bank Statement (Direct Deposit)
  • Compensation Award Letter
  • Court Award Letter
  • Pension Statement
  • Public Assistance Records
  • SSI Child Disability Benefits
  • Social Security Benefits
  • Housing Authority Verification
  • TANF – Temporary Assistance for Needy Families/Work First
  • Cash Public Assistance
  • Other verifiable sources are considered
  • Current Federal Tax Return (individual or joint)
  • Birth Certificate
  • Decree of Court (to show number in household)
  • Divorce Decree (change in household size)
  • Landlord Statement must include contact name and phone number.
  • Lease Agreement
  • Marriage Certificate
  • Medical Card
  • Public Assistance/Social Service Agency Records
  • Public Housing Authority (if Resident or on Waiting List)
  • Telephone Verification
  • Other verifiable sources of proof of household size will be considered



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