Sliding Fee Scale
Your percentage is determined by your household size and total household income. The total charge for your visit is determined by adding the office visit charge and all other charges for services that were ordered during your visit. Other charges may include lab tests, immunizations or injectable medications. You will be billed according to your qualified percentage rate.
ALL SLIDING FEE SCALE PAPERWORK MUST BE COMPLETED BEFORE ANY TYPE OF DISCOUNT WILL BE APPLIED TO YOUR BILL.
PRESUMPTIVE (ESTIMATED). ELIGIBILITY IS FOR FIRST VISIT ONLY.
IF ALL PAPERWORK IS NOT COMPLETE, YOU WILL HAVE TO PAY THE FULL CHARGE FOR ALL FOLLOW-UP VISITS INCLUDING LABS, SHOTS, AND/OR TESTING BEFORE THE SERVICES WILL BE PERFORMED.
Total charges cannot be determined before the visit, Any prices quoted before the completion of the visit, should be considered an estimate only.
If your total charges are more than the amount you paid at the time of service, you will be billed for the remaining balance. Monthly payments must be paid on all remaining balances until balance is paid in full.