Free Sample Sliding Fee Schedule Policy for Your Practice

Utilize this complimentary sliding fee schedule policy in your independent practice to assist patients with bill payments. By implementing this policy, you can enhance financial accessibility and ensure affordable healthcare for all your patients.

Free Sample Sliding Fee Schedule Policy for Your Practice

Sliding Fee Schedule Policy Sample Template

Sliding Fee Discount Program Policy

Purpose: This program is designed to provide discounted care to individuals who lack the means to pay for their healthcare services, whether they are uninsured or underinsured.

Policy Statement: [Insert Practice Name] is committed to offering a Sliding Fee Discount Program to all individuals who are unable to pay for their healthcare services. We base program eligibility on a person's financial ability to pay and do not discriminate based on age, gender, race, sexual orientation, creed, religion, disability, or national origin. To determine eligibility, we use the Federal Poverty Guidelines, which can be found at [insert link] and are updated annually to create the sliding fee schedule.


1. Notification: [Insert Practice Name] will notify patients about the Sliding Fee Discount Program by:

  • Providing an explanation of our Sliding Fee Discount Program and offering an application form on our website.
  • Placing notifications about the Sliding Fee Discount Program in the clinic waiting area.

2. Provision of Services: All patients seeking outpatient services at [Insert Practice Name] are assured that they will receive services regardless of their ability to pay. No one is refused service due to a lack of financial means, as long as they complete the application process and are found eligible.

3. Requests for Discount: Requests for discounted services may be made by patients, family members, social services staff, or anyone aware of existing financial hardship. Discounted services will be effective from the date of application approval going forward, and information and forms can be obtained from the Front Desk.

4. Administration: The Sliding Fee Discount Program will be administered through [Title of Staff Member Responsible for Handling Program] or their designee. Information about the policy and procedure will be provided, and assistance will be offered after the application process. Dignity and confidentiality will be respected for all individuals seeking or receiving charitable services.

5. Alternative Payment Sources: All alternative payment resources must be explored, including third-party payment from insurance(s) and Federal and State programs.

6. Application:

  • The patient or responsible party must complete the Sliding Fee Discount Program application in its entirety.
  • By signing the application, individuals authorize [Insert Practice Name] to access and verify income as disclosed on the application form.
  • Providing false information on the application will result in the revocation of all Sliding Fee Discount Program discounts, and the full balance of the account(s) will become payable immediately.

Initial Application: If an application cannot be processed due to missing information, the applicant has two weeks from the date of notification to supply the necessary information without changing the application date. Failure to provide the requested information within two weeks will result in re-dating the application to the date of submission.

Renewal Applications: Individuals who receive discounted services under this policy are required to submit updated applications every 12 months or if their financial situation changes. Failure to meet the annual financial information requirement may result in ineligibility for the Sliding Fee Discount Program. [Insert Practice Name] will send a notice to patients who are delinquent in meeting the renewal requirement, giving them 10 business days to submit the required financial information. Failure to submit the renewal information will result in ineligibility for discounted services as of the notice date.

7. Discounts: Discounts are determined based on income and family size. [Insert Practice Name] defines a family as the head of the household, spouse, and dependent children.

8. Income Includes: Earnings, unemployment compensation, workers' compensation, Social Security, Supplemental Security Income, public assistance, veterans' payments, survivor benefits, pension or retirement income, interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources. Noncash benefits (such as food stamps and housing subsidies) do not count.

9. Requirements: Applicants must provide:

  • Prior year W-2
  • The two most recent bank statements
  • The two most recent pay stubs
  • Self-employed individuals must submit details of the most recent three months of income and expenses for the business.
  • Adequate information must be provided to determine eligibility. Self-declaration of income may only be used in special circumstances, such as participants who are homeless. Patients unable to provide written verification must submit a signed statement of income and the reason for being unable to provide independent verification. This statement will be reviewed, and the sliding fee percentage will be determined by management.

10. Updates: The sliding fee schedule will be updated during the first quarter of each calendar year with the latest federal poverty guidelines.

11. Notice: The Sliding Fee Discount Program determination will be provided in writing, including the percentage of the write-off or the reason for denial. If the application is approved for less than a 100% discount or denied, the patient and/or responsible party must establish payment arrangements with [Insert Practice Name] immediately. Applicants may reapply after 12 months have expired or if there has been a significant change in family income.

12. Refusal to Pay: If a patient verbally expresses unwillingness to pay or leaves the premises without paying for services, the patient will be contacted in writing regarding payment obligations. If the patient is not on the sliding fee schedule, a copy of the Sliding Fee Discount Program application will be sent with the notice. If the patient does not make an effort to pay or fails to respond within 60 days, this constitutes refusal to pay. [Insert Practice Name] may explore options including offering a payment plan, waiving charges, or referring for collections efforts.

13. Storage of Information: Information related to Sliding Fee Discount Program decisions will be maintained and preserved in a centralized confidential file located in the office of [Title of Staff Member Responsible for Handling Program] to maintain the dignity of those receiving free or discounted care.

Related Posts

Subscribe to The Practice

Your weekly practice check-up delivered directly to your inbox for independent practitioners.