Income Guidelines for 2019
Printable Forms for New Patients
The following forms can be downloaded and printed. They are in PDF format and will require a PDF reader such as Adobe PDF Reader or equivalent browser plugin to properly view.
These fees are applied only to the medical office.
Our Dental office has a separate Sliding Scale that is used. For more information on this feel free to give us a call.
What to Bring on Your First Visit
Blount Rural Health Center operates on a Sliding Fee Scale. Discounts are offered depending upon family income and size. A sliding fee schedule is used to calculate the basic discount and is updated each year using federal poverty guidelines. A copy of previous year income tax or check stubs must accompany the application. The only parties that can be claimed on the application are family members claimed on the Federal Income Tax Report. A minimum sliding fee copay of $40 will be paid at the time services are rendered. Once approved, the discount will be honored for one year, after which you must reapply. You are also instructed to reapply if any change in income occurs. A completed application including required documentation must be on file and approved by the office manager or designated staff member before a discount will be granted. The discount is applied to office visits supplied by clinic providers. The discount is NOT applied to in-office laboratory services, reference laboratory tests and consulting diagnostic interpretations. The discount is NOT applied to out-of-office referred care.
Previous years Federal Tax and W-2 forms for all working persons claimed on your taxes.
- These are required yearly. (All patients must provide)
- A copy or the original letter, “Proof of Pending Disability” or a letter from your attorney indicating you have applied for disability, or
- A copy or the original of the last two pay stubs from anyone in the house hold that is working, or
- Proof of unemployment benefits, or
- A Employment Verification Form, (found on this website), or
- Incarceration release paper work or probation/parole paperwork, or
- Class schedule
- All current medication, including all over the counter medications that you take. Please bring bottles. (Do not bring Insulin)