As a National Health Service Corps site, Pediatric Associates of Pikeville promises to serve all
patients. We do not deny services based on a person's race, color, sex, age, national origin,
disability, religion, gender identity, sexual orientation, or inability to pay. Our clinic accepts
insurance, including Medicaid, Medicare, and Children's Health Insurance Program (CHIP).
We offer discounted fees for patients who qualify. Our staff is available to assist you in
determining your eligibility for a variety of health benefits coverage options. These options may
include a sliding fee scale discount, special grant-provided services, or public-funded health care
coverage. Eligibility is based on gross household income and family size. To determine
eligibility, you (the patient) must bring ONE of the following items along with a completed
Sliding Fee Discount Program Application:
If you have none of the above items available, you must provide a letter of reference from any
501(c)(3) (non-profit) organization on their letterhead (for example, your church). The
patient/responsible party must complete the Sliding Fee Discount Program Application in its
entirety.
The chart below shows the percentage discounts available based upon NHSC guidelines for
family size and income up to 200% of Federal poverty guidelines. Individuals or families earning
at or below 100% of the Federal Poverty guidelines will incur a nominal fee of $40.00 per office
visit for necessary medical treatment.
patients. We do not deny services based on a person's race, color, sex, age, national origin,
disability, religion, gender identity, sexual orientation, or inability to pay. Our clinic accepts
insurance, including Medicaid, Medicare, and Children's Health Insurance Program (CHIP).
We offer discounted fees for patients who qualify. Our staff is available to assist you in
determining your eligibility for a variety of health benefits coverage options. These options may
include a sliding fee scale discount, special grant-provided services, or public-funded health care
coverage. Eligibility is based on gross household income and family size. To determine
eligibility, you (the patient) must bring ONE of the following items along with a completed
Sliding Fee Discount Program Application:
- current year's tax form (1040 form),
- 2 current pay stubs,
- 1 unemployment stub, or
- letter from employer on letterhead that states your salary or wages.
If you have none of the above items available, you must provide a letter of reference from any
501(c)(3) (non-profit) organization on their letterhead (for example, your church). The
patient/responsible party must complete the Sliding Fee Discount Program Application in its
entirety.
The chart below shows the percentage discounts available based upon NHSC guidelines for
family size and income up to 200% of Federal poverty guidelines. Individuals or families earning
at or below 100% of the Federal Poverty guidelines will incur a nominal fee of $40.00 per office
visit for necessary medical treatment.
Persons signing the Sliding Fee Discount Program Application authorize our clinic to confirm
income as disclosed on the application form. Providing false information on the application will
result in discounts being revoked and the full amount of the account being restored and payable
immediately. If further information is needed for the application, our staff will contact the patient
and will allow two weeks in which to provide this information to the clinic. After two weeks, the
patient’s application will be redated from the date the information is received. Any expenses
incurred during this delay will be the responsibility of the patient. The discounted scale will not
apply to these charges.
income as disclosed on the application form. Providing false information on the application will
result in discounts being revoked and the full amount of the account being restored and payable
immediately. If further information is needed for the application, our staff will contact the patient
and will allow two weeks in which to provide this information to the clinic. After two weeks, the
patient’s application will be redated from the date the information is received. Any expenses
incurred during this delay will be the responsibility of the patient. The discounted scale will not
apply to these charges.
***To view fill out the application, please press the button below to download the document. You will then be able to fill it out.***
Pike Peds Sliding Fee Application | |
File Size: | 881 kb |
File Type: |