Sliding Fee Scale

Sliding Fee Scale at Compassion Health Care

Caswell Family Medical Center in Yanceyville, NC, and James Austin Health Center in Eden, NC offer the Sliding Fee Scale Program to ensure that our community has access to quality healthcare services, even if they are unable to pay.

The sliding fee scale allows us to offer a reduced fee to those individuals who qualify. Eligibility for the sliding fee scale is based on income and family size.

If you have questions or problems navigating the application, please call Compassion Health Care, Inc. and ask to speak with someone in our Billing Department.

Sliding Fee Scale Application

Name*
First Middle Last
Date of Birth*
Month
Day
Year
Email
Enter Email Confirm Email
Number of people in your household including yourself*
Please complete the following information for any other members of your household:
Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Current CHC Patient?*
- Yes
- No
Please complete the following information for any other members of your household:
Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Current CHC Patient?*
- Yes
- No
Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Current CHC Patient?*
- Yes
- No
Please complete the following information for any other members of your household:
Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Current CHC Patient?*
- Yes
- No
Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Current CHC Patient?*
- Yes
- No
Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Current CHC Patient?*
- Yes
- No
Please complete the following information for any other members of your household:
Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Current CHC Patient?*
- Yes
- No
Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Current CHC Patient?*
- Yes
- No
Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Current CHC Patient?*
- Yes
- No
Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Current CHC Patient?*
- Yes
- No
Please complete the following information for any other members of your household:
Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Current CHC Patient?*
- Yes
- No
Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Current CHC Patient?*
- Yes
- No
Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Current CHC Patient?*
- Yes
- No
Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Current CHC Patient?*
- Yes
- No
Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Current CHC Patient?*
- Yes
- No
Please provide the following based on "MONTHLY" income for everyone listed.
Do You Have Income?*
Patient Name*
First Last
Patient Account Number*
In order to qualify for the sliding fee, I am signing this letter which serves as a "Self Declaration" indicating that I have no income from any sources. I understand that I am responsible for my co-pay once I qualify for CHC's Sliding Fee. I fully understand the importance of reporting any income changes.
How are you supporting yourself?
Patient Signature*
First Last
Date*
Month
Day
Year
Salary (Monthly)
Unemployment (Monthly)
Social Security (Monthly)
Pension/Retirement (Monthly)
Rental Income/Dividends (Monthly)
Interest (Monthly)
Spousal Support (Monthly)
Child Support (Monthly)
Foster Care (Monthly)
Disability (Monthly)
Other Monthly Income
Other Monthly Income
Total Monthly Income from All Sources:
Please attach proof/verification for each of the income sources indicated above.
File
Max. file size: 128 MB.
Type your name below to certify that the above information concerning my income is true and complete and that I have no income other than that listed above. I promise to notify CHC at once if there is a change in my income, family size, mailing address, or telephone number.
Signature*
Date*
Month
Day
Year
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

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Sliding Fee Scale at Compassion Health Care

Sliding Fee Scale Application

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Sliding Fee Scale at Compassion Health Care

Sliding Fee Scale Application

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