Sliding Fee Application

Thank you for your interest in Horizon Health Care, Inc.’s Sliding Fee Program. This program is intended to help defer some of the out-of-pocket medical and dental expenses for individuals with or without insurance. In order to qualify we require that you provide documentation of your household income. If this is your first visit to one of our clinics we will allow you to self-declare your income and provide documentation following the visit to avoid delaying care but you must provide documentation if you wish to qualify for a reduction in fees for any subsequent visits.


If you wish to apply for a sliding fee discount please follow the directions below, fill out the attached application in its entirety and provide the requested documentation. You may qualify for fee reductions retroactively prior to the date your application is received if the proper documentation is provided. The amount of your fee reduction is determined by the Federal Poverty Guidelines with a minimum fee for office visits of $20 for medical and $35 for dental.


STEP 1) FILL OUT THE SLIDING FEE APPLICATION. Please remember to include all household members and sign your application.


STEP 2) PROVIDE PROOF OF YOUR INCOME. Please provide one of the following documents for ALL members of your household (related and unrelated) to show household income:

  • Two most recent paystubs
  • Current Tax Return
  • Current W-2s from all employment
  • Bank Statements showing all activity for the last three months
  • Social Security or Unemployment Award Letter
  • Amounts received in public assistance (rental assistance or food stamps, etc.) or a signed Release of Information

If you do not receive income from any source please provide one of the following:

  • Letter from a government office explaining the benefits you do or do not qualify for (unemployment office or social security office, etc.).
  • Denial letter for an application of benefits (must be dated within the last 3 months).
  • Anyone claiming to have no income but lacks a documented explanation will be required to reapply and submit a completed sliding fee application each visit.

STEP 3) RETURN YOUR SLIDING FEE APPLICATION, along with the supporting documentation, to the front desk of any of our Horizon dental or medical clinics or you may mail it to our Horizon Health Care Billing Department: 602 1st St NE Suite 1, Wessington Springs, SD 57382.


STEP 4) PAY YOUR CO-PAY OR FEES FOR TODAY’S OFFICE VISIT. The Billing Department will process your application and send you a letter in the mail explaining whether or not you qualify based on your application. If additional documentation is needed they will contact you by telephone or mail. Please allow up to 30 days for processing your application after it is received.


If it is determined that you do not qualify for our sliding fee program you will be responsible for any charges not covered by insurance. If it is determined that you do qualify for our sliding fee program a credit will be given if you have overpaid for your clinic visit and have no other outstanding bills or past bad debt to Horizon Health Care, Inc.


If you do not have any income from the past month and are going to self-attest today, you will need to fill out this application in the clinic at the time of your appointment. If you are providing income verification, please continue to fill out the form below.

Source includes earnings, unemployment compensation, worker’s compensation, social security, supplemental security income, public assistance, veterans’ payments, survivor benefits, pension or retirement income, interest, dividends, rents, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources

Household

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