Applicants must provide one of the following:
- prior year W-2
- two most recent pay stubs
- letter from employer
- Form 4506-T (if W-2 not filed)
- and/or any other source of income
Self-employed individuals will be required to submit detail of the most recent three months of income and expenses for the business. Adequate information must be made available to determine eligibility for the program. Self-declaration of Income will only be used in special circumstances. Specific examples include participants who are homeless. Patients who are unable to provide written verification must provide a signed statement of income, and why (s)he is unable to provide independent verification. This statement will be presented to GLIIHC’s Executive Director or his/her designee for review and final determination as to the sliding fee percentage. Self-declared patients will be responsible for 100% of their charges until management determines the appropriate category.
Those with incomes at or below 100% of poverty will receive a full 100% discount. Those with incomes above 100% of poverty, but at or below 200% of poverty, will be charged according to the attached sliding fee schedule. The sliding fee schedule will be updated during the first quarter of every calendar year with the latest federal poverty guidelines.
Patients receiving a full discount will not be assessed any fees per visit; except a nominal $30 fee for a routine/preventative visit. Patients will not be denied services due to an inability to pay.