Thank you for your interest in Horizon Health’s Sliding Fee Discount 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 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 $25 for medical and behavioral health. Dental is $40.

STEP 1) FILL OUT THE SLIDING FEE APPLICATION.

Please remember to include all household members and sign your application.

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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 (back-to-back) paystubs dated within 30 days of the date of the applications
Current Tax Return, 1040
Social Security Award Letter (current year letter with monthly income noted for each person receiving benefits)
Unemployment Award Letter or statement (available through the local Job Service office)
Economic Benefits Letters – The income will be used, not the benefit amount
Self-Declaration Form – Financial support document signed by the individual/organization supporting you. Must be completed in full, which includes signature and date.

Self-Declaration Form

Formulario de Autodeclaración de Salud

Patients who have not submitted income verification have (10) ten business days to bring in their income verification or will be billed for the full cost of services rendered.

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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:

Horizon Health Enrollment Services Department
PO Box 99
Howard, SD 57349

STEP 4) PAY YOUR CO-PAY OR FEES FOR TODAY’S OFFICE VISIT.

The Enrollment Services 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 Discount Program you will be responsible for any charges not covered by insurance. If it is determined that you do qualify for our Sliding Fee Discount 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.

Sliding Fee Application

Applicant Name*
First Middle Last
Email*
Date of Birth*
Address*
Street Address Address Line 2 City State ZIP Code
Primary Phone*
Secondary Phone
File Uploads*
Please provide one of the following documents for ALL members of your household (related and unrelated) to show household income: Two most recent paystubs (back-to-back) paystubs dated within 30 days of the date of the applications - Current Tax Return, 1040 - Social Security Award Letter (current year letter with monthly income noted for each person receiving benefits) - Unemployment Award Letter or statement (available through the local Job Service office) Economic Benefits Letters - The income will be used, not the benefit amount - Self-Declaration Form - Financial support document signed by the individual/organization supporting you. Must be completed in full, which includes signature and date. Patients who have not submitted income verification have twenty (20) business days to submit their income verification or will be billed for the full cost of services rendered.
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB, Max. files: 10.
Please fill out each field for each person in the household (Include yourself as a household member)*
First and Last Name Date of Birth Source of Income Sex Relation

Click the + icon to add another person.
Income Verification - I have provided the following sources of income verification for each household member with a source of income with the application:*
- Current Income Tax Document (Form 1040)
- Two most recent/consecutive (back-to-back) paystubs dated within 30 days of the date of application
- Social Security Award Letter (current year letter with monthly income noted - for each person receiving benefits)
- Unemployment Benefit Letter or statement (available through the local Job Service office)
- Economic Benefits Letters - The income will be used, not the benefit amount
- Self-Declaration Form - Financial support document signed by individual/organization supporting you. Must be completed in full, which includes signature and date.
- I have not submitted any sources of income verification and understand that I have ten (10) business days to bring in income verification or I will be billed for the full cost of services rendered.
Agreement*
I acknowledge that if I qualify for the Sliding Fee Discount Program, I will be charged a nominal fee for each visit based on the services provided. I agree to notify Horizon Health promptly if there are any significant changes to my household or income that could affect my eligibility for the Sliding Fee Discount Program. I understand that I must apply for the Sliding Fee Discount Program on an annual basis to maintain eligibility. I understand that I am required to list all family members and wage earners in my household and provide income verification to qualify for the program. I understand that if I am eligible for reduced fees but fail to make the required payments, I must contact Enrollment Services to discuss my situation and establish a payment plan. I understand that payments are due on the date of service, and I will reach out to Enrollment Services if I need assistance with payments due to financial hardship. I acknowledge that intentionally providing false information may result in the termination of my eligibility for the Sliding Fee Discount Program at Horizon Health, and I will be responsible for paying the full, usual, and customary charges. By my signature below, I certify that the information provided above is true and accurate to the best of my knowledge.
- I agree to the above statement.
Signature*
Date*
Relationship to Applicant if Guardian or Legal Representative
*Documentation of your legal authority to act on behalf of the patient must be provided at time of service.
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