Please review the information below should you be interested in participating in our sliding fee schedule at our practice.

 

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Sliding Fee Application: Click here for Sliding Fee Application

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Purpose: To make comprehensive primary care services available and accessible to uninsured or underinsured patients by establishing fees that are affordable to them and in accordance with federal regulations. A Sliding Fee Discount Program will be provided to eligible individuals based on their ability to pay. The ability to pay will be determined by the household annual income and family size.

North Florida Pediatrics will offer a Sliding Fee Discount Program to all who are unable to pay for their services. North Florida Pediatrics will base program eligibility on a person’s ability to pay and will not discriminate on the basis of an individual’s race, color, sex, national origin, disability, religion, age, sexual orientation, or gender identity. The Federal Poverty Guidelines are used in creating and annually updating the sliding fee schedule to determine eligibility.

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Procedure:

The following guidelines are to be followed in providing the sliding Fee Discount Program.

Notification: North Florida Pediatrics will notify patients of the Sliding Fee Discount Program by:

 

• Notification of the Sliding Fee Discount Program will be offered to each patient who reports no Insurance upon admission or underinsured.

• An explanation of our Sliding Fee Discount Program and our application form are available on North Florida Pediatrics website.

• North Florida Pediatrics places notification of Sliding Fee Discount Program in the clinic waiting area.

 

Requests for discount: Requests for discounted services may be made by patients, family members, social services staff or others who are aware of existing financial hardship. The Sliding Fee Discount Program will only be made available for clinic visits. Information and forms can be obtained from the Front Desk and the Business Office.

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Administration: The Sliding Fee Discount Program procedure will be administered through the Business Office Manager or his/her designee. Information about the Sliding Fee Discount Program policy and procedure will be provided to patients. Staff are to offer assistance with the completion of the application. Dignity and confidentiality will be respected for all who seek and/or are provided with health care services.

 

Completion of Application: The patient/responsible party must complete the Sliding Fee Discount Program application in its entirety. Staff will be available, as needed, to assist patient/responsible party with applications. By signing the Sliding Fee Discount Program application, persons are confirming their income to North Florida Pediatrics as disclosed on the application form.

 

 Eligibility:

1.  Family is defined as: a group of two people or more (one of whom is the householder) related by birth, marriage, or adoption and residing together; all such people (including related subfamily members) are considered as members of one family. North Florida Pediatrics will also accept non-related household members when calculating family size.

2. Income includes: gross wages; salaries; tips; Social Security; Retirement Pension; Child support; Alimony; Other may include: Dividends; royalties; income from rental properties, estates, and trusts;

 

Income verification: Applicants may provide one of the following: prior year W-2, two most recent pay stubs, letter from employer, or Form 4506-T (if W-2 not filed). Self-employed individuals will be required to submit detail of the most recent three months of income and expenses for the business. Adequate information must be made available to determine eligibility for the program. Self- declaration of Income may be used. Patients who are unable to provide written verification may provide a signed statement of income.

 

Discounts: Those with incomes at or below 100% of poverty will receive a full 100% discount for health care services. Those with incomes above 100% of poverty, but at or below 200% of poverty, will be charged a nominal fee according to the attached sliding fee schedule. The sliding fee schedule will be updated during the first quarter of every calendar year with the latest Federal Poverty Line Guidelines.

 

Nominal Fee: Patients receiving full discount will be assessed a $10 nominal chare per visit. However, patients will not be denied services due to an inability to pay. The nominal fee is not a threshold for receiving care and thus, is not a minimum fee or co-payment.

 

Waiving of Charges: In certain situations, patients may not be able to pay the nominal or discount fee. Waiving of charges must be approved by North Florida Pediatrics’ designated official. Any waiving of charges should be documented in the patient’s file along with an explanation. (e.g., ability to pay good will, health promotion event)

 

Applicant notification: The Sliding Fee Discount Program determination will be provided to the applicant(s) in writing and will include the percentage of Sliding Fee Discount Program write off, or, if applicable, the reason for denial. If the application is approved for less than a 100% discount or denied, North Florida Pediatrics will work with the patient and/or responsible party to establish payment arrangements. Sliding Fee Discount Program applications cover any balances incurred within 6 months after the approved date. Unless their financial situation changes significantly. The applicant has the option to reapply after the 6 months have expired or anytime there has been a significant change in family income. When the applicant reapplies, the look back period will be the lesser of six months or the expiration of their last Sliding Fee Discount Program application.

 

For any questions or concerns, please contact us at (386) 758-0003.

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