Sliding Scale Application

1. Sliding Scale Eligibility and Application Process 

• Clients may request consideration for the sliding scale fee discount during intake, scheduling, billing discussions, or at any time financial hardship is identified.
• Eligibility shall be based on household income, family size, insurance status, and financial need.
• The agency shall review each request in a fair, consistent, and non-discriminatory manner.

2. Eligibility and Required Documentation 

• To determine eligibility, clients shall be asked to provide documentation of household income and family size.
• Acceptable documentation may include recent pay stubs, W-2 forms, most recent tax return, employer verification, benefit award letters, or other documents that reasonably verify income.
• Documentation of family size may include tax returns, birth certificates, custody documentation, or other records showing legal dependents.
• Clients should provide requested documentation within 14 days of the initial visit or request for the sliding scale fee discount.
• If documentation is unavailable, such as in cases of homelessness, unemployment, lack of formal income, or other financial hardship, the agency may accept a signed self-declaration of income form with approval from the Clinical Director or designated agency representative.

3. 2026 Sliding Scale Fee Schedule 

• The agency shall use the current Federal Poverty Guidelines to determine client fee responsibility.
• The sliding scale fee schedule shall be reviewed and updated annually within 30 days of the publication of the updated Federal Poverty Guidelines.

Household Income (% of FPG)Patient Responsibility

At or Below 100%: Nominal Fee Only $20.00

101% – 125%: 20% of Standard Fee

126% – 150%: 40% of Standard Fee

151% – 175%: 60% of Standard Fee

176% – 200%: 80% of Standard Fee

Above 200%: Full Fee (Standard Agency Rate)
5. Approval, Notification, and Documentation of Determination 

• The agency shall review the client’s submitted documentation and determine the appropriate fee responsibility based on the current sliding scale fee schedule.
• The client shall be notified of the approved fee amount.
• The sliding scale determination shall be documented in the client record or billing record.
• Eligibility shall be reviewed at least annually or sooner if the client reports a significant change in income, family size, insurance status, or financial circumstances.