Fee
Information
The
Adams County Health Center’s policy is to provide
essential health services regardless of the patient’s
ability to pay. Discounted fees are available. The amount
depends on family income and size.
Sliding
Fee Applications:
The discounts apply to all services offered at the Adams County Health Center
facility in Council, including primary care, laboratory, x-ray, dental, telepharmacy
and behavioral health (PSR).
However,
the sliding fee discounts DO NOT apply to any services
performed away from the Adams County Health Center facility,
including consultations, reference lab testing, etc. To
view or print out a copy of the Sliding
Fee Application form click here. You need to have the free Adobe Acrobat
reader to view the form.
Sliding
Fee Requirements:
When applying for the sliding fee program, patient identification and address
must be provided. Acceptable methods include a valid driver’s license,
state ID card, employment, or other picture ID. A Social Security Number is
needed for the application form and a copy of the SSN card is necessary. A
copy of a Social Security card or birth certificate is required for underaged
dependents.
A
copy of the prior year’s income tax return for each
individual living in the household is required to verify
income. If employment has changed since the filing of that
return, copies of the last three months paycheck stubs
or payroll records showing year-to-date earnings are required.
If
the applicant has had no income for three months or more,
this must be verified through some other official agency
records, bank records, or by written statement from a landlord
or other person outside the household having knowledge
of the applicant’s financial situation.
If
You Feel You May Qualify:
Please complete a Financial Assistance/Sliding Fee Program Application and
return it to the Adams County Health Center office.
If
you wish to apply the sliding fee to your current visit,
you will need to return the completed application and submit
your verification data with five (5) working days of the
visit.
Approval
for Sliding Fee Program:
You will be notified in writing when your application has been processed regarding
your eligibility.
Term
of Sliding Fee Program:
Once approved, your application will be valid for a term of six (6) months
unless there is a substantial change in household makeup or income.
It
is your responsibility to reapply when the current eligibility
period has expired.
Income
Thresholds for Sliding Fee Program Discounts:
The annual income & monthly income threshold tables are shown for each
of the services available. You can review them here (requires that Adobe Acrobat
Reader be installed on your computer
to view- see below*):
· Primary Care
· Laboratory
· X-Ray
· Dental
· Behavioral Health (PSR)
· Telepharmacy
*Click
the following icon to download the latest Adobe Reader.
(28mb
download - latest version requires Windows XP)
If
you have any questions, please contact the Adams County
Health Center at
208-253-4242.
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