SLIDING FEE APPLICATION
At Little River Medical Center, we provide services to all and offer a sliding scale fee based on income and family size. This program reduces the cost of care for eligible patients without insurance or with large insurance deductibles. Federal grants make it possible us to provide services for uninsured patients but also for individuals enrolled in private insurance plans that have large deductibles and other out-of-pocket costs. This program ensures access to affordable care for all.
It is necessary to provide documentation of income for every member of your family. Following are forms of acceptable documentation:
- Preferably 2-3 current consecutive pay stubs
- Bank statements showing automatic gross income deposits
- Supplemental Nutrition Assistance Program (SNAP) documents that provide family size and income
- Your most current federal tax returns. If self-employed, a business income tax return with the appropriate additional tax schedule worksheet
- Statement from employer
- Documentation showing additional income from alimony or child support
- Statement from Social Security Office
- Current Unemployment Benefits statement
Once qualified, your application will remain valid for 12 months. It will be necessary to renew your application each year with updated information.
