Income-Based Sliding Fee Scale

Fairfield Community Health Center never turns anyone away due to insurance status, employment status, or ability to pay for services. We offer a sliding fee scale to our patients who may benefit from it, including the uninsured.

 

If you think you qualify for the sliding-fee scaled, print the application above and bring it with you to our offices, along with one of the acceptable forms of income documentation listed below.

Acceptable Income Documentation

  • Pay Stubs – 1 month of gross household earnings

  • Unemployment Benefits

  • Workers Compensation Benefits

  • Social Security Benefits – Patient must provide an award letter

  • Child Support

  • Alimony

  • Tax Documents - W2’s, 1099, tax return (adjusted gross income)