Sliding Fee Application
Applying for Sliding Fee Scale
Community Health Center of Central Wyoming (CHCCW) strive to ensure every patient receives quality care regardless of ability to pay. All CHCCW clinics offer a sliding fee scale to help you pay for the services you receive. The fee scale is based on income and family size.
At your financial assistance appointment, you will need to provide proof of your household income and family size to verify your eligibility. If you do not have any documented income at this time, please contact your local clinic for assistance.
To apply for our sliding fee scale, please contact us at (307) 233-6000 (select option #2) to discuss documentation needed for eligibility. Below are some commons forms of eligibility proof:
- One month of pay stubs for all employed adults
- Unemployment check stubs
- Social Security statement
- Most recent year’s federal income tax return
Digital Application
If you are unable to book an appointment for financial assistance, you may use the link below to access the application online.
Please allow 7 to 10 business days when applying online. A representative from CHCCW will reach out to you via email.
A PDF copy of the sliding fee scale application is available here. If opting for the paper application, please print and complete the application. Return the completed application via mail, email, drop off, or fax.
Sliding Fee Scale FAQs
What is a Sliding Fee Scale?
It is the policy of CHCCW to offer a board-approved Sliding Fee Scale Discount (SFSD) program to all individuals and families with annual incomes at or below 200% of current Federal Poverty Guidelines. No aspect of the SFSD, including the procedures for assessing patient eligibility, or the procedure for collecting payments, will create barriers to health care services. The SFDS is made available to reduce barriers to care for patients that are uninsured or underinsured. The SFDS is developed and reviewed annually based on community need and changes in the health care community.
The SFSD program is available for services at CHCCW and is available to patients regardless of their ability to pay.
Why do we have a Sliding Fee Scale?
Community Health Center use a Sliding Fee Scale to reduce financial barriers related to medical, behavioral, pharmacy, and dental costs. Patients are expected to carry some portion of the cost or nominal fee. Bring your co-pay and make payments on your bill to help CHCCW keep our doors open to all members of the community.
Who is eligible for the Sliding Fee Scale?
The SFSD program is non-discriminatory and every patient is eligible to apply. If you fall within the household and income requirements, you will automatically be placed on the appropriate slide.
How do I apply for the SFSD?
Walk in sliding fee scale appointments are welcome.
Patients are encouraged to call to schedule an appointment with patient services. Financial information must be provided on or before the day of visit in order to qualify/obtain an SFSD. You will need to provide your household income and size.
What is considered household income?
The types of income used to determine eligibility for SFSD include, but are not limited to, the following:
- Employment and cash earnings
- Unemployment compensation
- Worker’s Compensation
- Social Security
- Supplemental Security Income
- Public assistance
- Veterans’ payments
- Survivor benefits
- Pension
- Retirement income
- Rents
- Royalties
- Income from estates
- Interest/Dividends
- Trusts
- Educational assistance (scholarships and grants used for living expenses)
- Alimony
- Child Support
- Assistance from outside the household
- Misc. sources
What information do I need to bring to CHC to receive SFSD?
Acceptable forms of proof to determine income include, but are not limited to, the following:
- Income Tax Return – A signed copy of the most recent tax return showing Adjusted Gross Income (AGI)
- Paycheck Stubs – Most recent pay stub(s) indicating gross pay
- Agency Letter – A letter from the Social Security Administration, Veterans Administration, or Social Service Agency (i.e., AFDC, Food Stamps, WIC) indicating income level
- Unemployment Verification – Paperwork from the Employment Securities Commission (ESC), proving unemployment status and the amount of unemployment compensation being received
- Court Documents – Official documents citing child support, or alimony as awarded by a judge accompanied by a statement of child support enforcement stating amount received *In the situation of spousal separation, a legal document such as a legal separation or divorce filing will be requested from the patient; but not required if self-declared
- Official Paperwork – Paperwork documenting retirement, disability, and/or SSI benefits
- Employer Letter – For those not receiving an actual pay check, a letter from the patient’s employer detailing current gross income and frequency of pay periods may be accepted. Contact information on company letterhead must be provided so that the information can be verified
- No Job/Other Income Source – A current-dated letter from an agency, friend, relative, or past employer, who knows the situation and is NOT living with the applicant, which includes the writer’s name, address, and phone number
- Self-Declaration Is acceptable if no other information can be provided