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As Federally Funded
Health Centers, First Choice Community Health Centers receives
a grant from the Bureau of Primary Health Care to provide
medical and dental services to the uninsured and underinsured
residents of Harnett County and surrounding areas.
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Our Sliding Fee
Program allows for reduced fees for services provided in the
clinics to all individuals and families who qualify. If
you apply and qualify at one location you will receive the
discount at all our clinic locations. |
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Sliding Fee Program |
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Basic Dental Visits |
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Expanded Dental
Procedures |
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Self-Pay Patients |
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Eligibility |
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Applying for
Sliding Fee Program |
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THE SLIDING FEE PROGRAM |
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is based on household size and income and may
reduce your bill to as little as $20.00. You may qualify
whether you have insurance or not. You may qualify even
though you have Medicare. |
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Find your household
size, and if the household's annual income is less than the
amount listed, you may qualify. |
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Family Size |
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Family
Income
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1 |
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20,801 |
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2 |
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28,001 |
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3 |
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35,201 |
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4 |
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42,401 |
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5 |
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49,601 |
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6 |
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56,801 |
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7 |
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64,001 |
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8 |
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71,201 |
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NOTE: For
family units with more than eight (8) members add $3,600 for
each additional member. |
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BASIC DENTAL VISITS: |
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Sliding fee patients
will be responsible for $20.00 per procedure performed for
basic dental care. |
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Basic Dental
services include and are limited to cleaning, restoration,
extractions, basic dental exams, and X-Rays (including
panoramic). |
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A hygiene visit
includes cleaning, exam and X-Rays and qualifies as one (1)
procedure. |
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If other procedures
are completed in the same visit then additional charges will
apply. For example, if two (2) fillings are completed on
the same visit as the hygiene visit, this would qualify as two
(2) additional procedures and therefore the patient would be
charged an additional $20.00. |
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EXPANDED DENTAL
PROCEDURES: |
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Charges for prosthetics, endodontics,
and repairs will be adjusted based on which income level of
the sliding fee scale the patient qualifies. |
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The following
provides the income ranges with the appropriate amounts: |
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Category A
- Patients with family income totaling 100%
or less
of the Federal Poverty Level (FPL) the patient will pay 25%
of dental
charges. |
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Category B
- Patients with income of 101%
to 175%
of the FPL, patient pays 50%
of dental charges. |
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Category C
- Patients with income of 175%
to 200%
of the FPL, patient pays 75%
of dental charges. |
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SELF-PAY PATIENTS: |
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are defined as families who have no dental
insurance and the total family income exceeds 200%
of the Federal Poverty Level for income. |
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Self pay patients
are responsible for 100% of all charges associated with the
dental visit. Any procedures requiring expanded
procedures must be paid for in advance prior to labs being
ordered or services being performed. |
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Payment arrangements
can be made in order to accommodate the need for payment
arrangements. |
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ELIGIBILITY: |
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for this program can be determined in our office. |
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To apply for the
Sliding Fee Program please come into our office prior to the
date of your next scheduled appointment or arrive 30
minutes prior to your appointment time so your
information can be updated. |
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Once you qualify,
you are eligible for the program for one (1) year from the
date of your application. |
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You have to renew
your application for this program every year. |
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APPLING FOR SLIDING FEE PROGRAM |
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Information
needed when applying for the Sliding Fee Program: |
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Proof of your income for all
family members (i.e. Pay stubs, tax returns, official
letters of Social Security or Disability). Employer
letter on company letterhead stating hourly wages and number
of hours worked per week. (Currently we do not accept
W-2 forms for proof of income.)
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Any persons 18 or older that do
not have income would have to obtain a Statement of Wages
from their local Social Security Office. This report
would show that no income has been reported for this
individual.
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When you use pay stubs for
income verification we would need enough stubs to cover a
30 day period. If you are paid weekly we would need
your last four (4) pay stubs; biweekly we would need the
last two (2) pay stubs; and if you are paid monthly we
would need the most recent pay stub.
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Social Security card(s) or ITN
card(s) for yourself and all other family members.
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A picture ID (i.e. Driver's
License, State ID, passport, etc.) for identification.
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A completed
Sliding Fee Program
Application (requires
Adobe Acrobat) or applications are
available at any of our five locations - just inquire at the
front desk.
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If you have any questions, please
ask any of our staff. |
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