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The Sliding Scale Fee Application provides a standardized process for patients to apply for reduced-cost care based on their financial circumstances. Many healthcare organizations, particularly community health centers, behavioral health practices, and nonprofit clinics, offer sliding scale fee schedules tied to federal poverty guidelines or internal affordability thresholds. This form collects the household and income information needed to determine which fee tier a patient qualifies for, ensuring that financial barriers do not prevent individuals from accessing necessary healthcare services.
The application captures the patient's employment status, employer information, total household size, gross annual household income, and sources of income including wages, Social Security, disability benefits, unemployment, and other assistance programs. Patients indicate whether they have applied for or been denied Medicaid or marketplace coverage, which helps care teams explore all available options before applying the sliding scale. A documentation upload section allows applicants to attach pay stubs, tax returns, benefit award letters, or a self-attestation of income for those without formal documentation.
This template is essential for federally qualified health centers, free clinics, behavioral health providers, substance abuse treatment facilities, and any practice committed to equitable access to care. Financial counselors use completed applications to assign patients to the appropriate fee tier, maintain documentation for HRSA compliance or grant reporting, and schedule annual redeterminations. By formalizing the sliding scale process, organizations ensure consistency and create an auditable record that supports both patient access and organizational sustainability.
What's included
- Patient demographics and contact information
- Household size and employment status documentation
- Gross income and income source enumeration
- Medicaid and marketplace coverage application status
- Income documentation upload
- Self-attestation and accuracy consent agreement with e-signature
Who uses this template
- Community health centers assigning patients to income-based fee tiers
- Behavioral health practices offering reduced-cost therapy and counseling
- Nonprofit clinics documenting sliding scale eligibility for grant compliance
- Financial counselors processing fee reduction applications consistently
All form fields
12 fields across 2 pages. Customize any field after signing up.
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