Sliding Fee



Harrisonburg Community Health Center offers affordable health care and dental care through the use of the sliding fee discount program to uninsured and under insured qualified individuals and families.  The Sliding Fee Discount Program Scale is based on the definition of federal poverty provided by the Department of Health and Human Services annually and is divided into four categories:  A, B, C, and D with fees as follows:

  • Slide A (100% FPGL and below) – $10 medical fee copay
  • Slide B (101-150% FPGL) – $20 medical fee copay
  • Slide C (151-175% FPGL) – $30 medical fee copay
  • Slide D (176-200% FPGL) – $40 medical fee copay

Copay fees are charged per visit.  There is no charge for Lab visits regardless of the number of tests completed at that visit for patients eligible for sliding fee discounts unless the patient also has commercial insurance.  The insurance will be billed by the lab processing vendor for those patients and any unpaid balance will be the patient’s responsibility.  The Sliding Fee Discount application needs to be renewed every year, and for those who provide a letter of support the application will need to be renewed every 6 months.  Members of the family are defined as the head of household, any spouse, custodial parent(s) and all financial dependents.  Dependents are those individuals the applicant is legally obligated to support.

Applicants MUST provide proof of all sources of income that apply for the last 30 days.  Accepted sources of proof of income include:

  • 1040 Tax Forms (no W2’s)
  • Social Security/Disability Letter
  • Unemployment Benefit Letter (no bank statements)
  • Letter of Support
  • Employers Letter (if paid in cash)
  • Pension Benefit Letter
  • Inheritance
  • Trust Funds
  • Veterans Benefits
  • Wages (if paid weekly the last 4 pay stubs, if paid bi-weekly the last 2 pay stubs)

Forms

Sliding Scale Application (English)

Programa de Descuento de Tarifa Flexible

Employment Verification Form (English)

Forma de Verificacion de Empleo

Letter of Support

Declaracion de Apoyo