SLIDING FEE SCALE

Unity Health on Main serves all patients regardless of ability to pay. However, services are not provided free of charge.

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 Eligibility for the sliding fee discount is determined by documented annual income and family/household size. Patients with a documented annual income of 200% or below the federal poverty level (FPL) are eligible for a sliding fee discount on all services we provide. 

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Patients with income at or below 100% of the federal poverty level (FPL) are charged a nominal fee; however, no established patient will be refused services due to inability to pay. Patients unable to pay the discounted fee at the time of service will be required to sign a payment plan agreement.

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Determining your eligibility for the sliding fee discount requires verification of your income. This information must be updated at least annually to continue your participation in the program. This information is only used to calculate your discount and is kept completely confidential.

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Sliding fee discounts for essential services are offered based upon family size and income. Proof of income is required. You may apply for sliding-fee discount at the front desk.

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How do I qualify?

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If you wish to apply for the Sliding Fee Discount you MUST show proof of gross annual income for all immediate family members living in your household. Gross income is ALL income from ALL sources before taxes.

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Acceptable Income Documentation for Sliding Fee Application Includes:

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• W-2/1099 forms from the previous tax year (Good for 12 months.)

• Paycheck Stubs. How often you are paid will determine what documentation is necessary (Good for 12 months.)

• Other considerations regarding check stubs:

  • We use GROSS pay

  • Check stubs must be concurrent

  • No older than 30 days

  • Tips are to be included as Gross Income

• Statement of benefits from SC Employment Security Commission

• Statement of income determination from SC Department of Social Services

• Copy of Social Security check or annual statement (Good for 12 months.)

• Copy of tax return from the previous tax year – Adjusted Gross Income (AGI) will be used to determine sliding fee income level (Good for 12 months.)

• Letter from an employer stating GROSS income and frequency (Good for 12 months.)

  • On letterhead (Company Information) OR notarized if person is employed by an individual

  • Signed by the employer/individual

  • Date of letter

  • No older than 30 days

  • Patient cannot sign as the “employer”

• Proof of court ordered Child Support and/or Alimony (Good for 12 months.)

• Statement from short-term disability showing the gross income amount (Good for 90 days.)

• Statement from long-term disability showing the gross income amount (Good for 12 months.)

• Worker’s Compensation showing the gross income amount (Good for 90 days.)

 

Self-Declaration of Income Form:

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There may be some circumstances when it is important that a patient be seen but does not have income documentation during their visit. A patient may apply using a self-declaration form.

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New or established patients can use a self-declaration form. Patients can use the self-declaration from one time in a rolling calendar year. The sliding fee designation expires after 10 days and on day 11, if the patient does not have sufficient income documents, he/she will be self-pay with no discount on the services rendered.