Sliding Fee Discount Program

Payment is expected at time of service. Please note that payment  in full at time of service will qualify for an additional discount-

10% for dental/medical, 15% for 65 and over dental only.

At Mountain Valleys Health Centers, our mission is to provide high quality health and dental services to our patients.  We bill most insurances, Medi-Cal, and Medicare, and we accept patients without regard to their financial status.  The Sliding Fee Discount Program helps ensure that cost is not a barrier to anyone in our community seeking health care services.  Please ask our staff if you would like more information about our Program – we are here to help!

 

To determine your eligibility for this Federally funded Program, you will need to complete an application for the Program and provide documentation of your income (or lack of income) and household size.  You must update this information at least annually to continue your participation in the Program.  This information is only used to calculate your discount and is kept COMPLETELY confidential.  If you have insurance with a high deductible, you may be eligible for our Sliding Fee Discount Program. 

 

Examples of documentation to show proof of income include:

  • W-2 form

  • Tax return (required if using self-employment earnings)

  • Pay stubs (2 are needed)

  • Social Security/SSI benefit statement letter

  • IRS Form 1099-G (unemployment benefits)

  • Bank statement showing direct deposit by name

  • Letter from an employer documenting employment and income

  • Unemployment payment stub

 

Patients who are unable to provide any reasonable proof of income must complete a Self-Declaration of Income Statement to be considered for the Program. 

 

You have 30 days from the date of service to submit a completed application with proof of income.  Until required documents have been submitted and eligibility has been determined, you are responsible for full fees.  If you apply at a later time, eligibility is NOT retroactive and you will be responsible for all fees.

 

Any patient declining to be assessed for eligibility in the Sliding Fee Discount Program by refusing to provide required information is not eligible for the Program.

Sliding Fee Application 
(English)

Sliding Fee Application 
(Spanish)