E.A. Hawse Health Center Sliding Fee Scale

Household Members

You pay 25% A

You pay 50% B

You pay 75% C

You pay 100%

1

0 – 13,867

13,868 – 17,333

17,334 – 20,800

20,801

2

0 – 18,667

18,668 – 23,333

23,334 – 28,000

28,001

3

0 – 23,467

23,468 – 29,333

29,334 – 35,200

35,201

4

0 – 28,267

28,268 – 35,333

35,334 – 42,400

42,401

5

0 – 33,067

33,068 – 41,333

41,334 – 49,600

49,601

6

0 – 37,867

37,868 – 47,333

47,334 – 56,800

56,801

7

0 - 42,667

42,668 – 53,333

53,334 – 64,000

64,001

8

0 – 47,467

47,468 –59,333

59,334 –71,200

71,201

9

0 – 52,267

52,268 – 65,333

65,334 – 78,400

78,401

For family units of more than 9 members, add $4,800 for each additional family member.

Proof of your total family income is required for the EAHHC sliding fee scale. A copy of your federal tax return should be used as proof of income. Social Security letter, public assistance checks, alimony and child support agreements are all acceptable form of proof of income. Any dependents living in the household must be verified. Parents should provide a copy of their children's social security card or birth certificate.

Dental labs are not eligible for sliding fee. Dental labs are partials, dentures, plates, etc. Medical labs and X-rays are added to your office visit and are billed per the above schedule. Medical labs are any test such as blood work, urine, etc.

Example 1: If you are married and have two children, the total household members would be “4”. If you total household income is $21,000 per year, you would qualify for sliding scale “A” which means you pay 25% of your office visit charge for both Medical & Dental. You pay 100% for any dental labs and 25% for any medical labs.

Example 2: If you are single parent and have five children, the total household members would be “6”. If your total household income is $21,000 per year, you would qualify for sliding scale “A” which means you may pay 25% of your office visit charges for both Medical & Dental.

You pay 100% for any dental labs and 25% for any medical labs.

Example 3: If you are married and have three children, the total household members would be "5". If your total household income is $49,900 per year, you would not qualify for sliding fee which means you pay 100% of all charges for medical and dental.

Payment by Cash, Check or Credit Card when services rendered.