Sliding Fee Discount Program (SFDP)

SHS offers access to quality health care for patients who do not have insurance or do not have enough insurance through a sliding fee discount program, with discounts available based on your current family size and income. The program can cover you for up to 12 months—a new application is required yearly or when your family size and income changes, whichever is sooner.

This program allows you to see providers at any SHS Community Health Center and offers access to lab, x-rays, and prescriptions at a discount. If you receive medical, dental, or behavioral health services from someone other than your SHS provider, you may be responsible for the full cost of that visit.

If you have been approved for our SHS Sliding Fee Discount Program, you are currently a patient at one of our health centers, and you are still struggling to afford your prescription medications, you might be eligible for our Prescription Assistance Program.

Click on the links below to download the presentation and flyer

What documents* do I need to bring to my appointment?

Completed Application (Link – attach form to allow download)
Photo ID

• Driver’s License
• Government-issued Identification Card/Passport

Wages and Salary

• Paycheck Stub (4 Consecutive Pay Periods)
• Current Income Tax Return

Self-Employed

• Signed and Dated Federal & PA State Income Tax Return and All Schedules
• Records of Earnings and Expenses

Social Security

• Award Letter
• Benefit Letter

Insurance Status

• A PA State Medicaid, Family Health Plus or Child Health Plus determination, if applicable.

Unemployment Benefits

• Award Letter
• Benefit Check

Child Support/ Alimony

• Letter from Court
• Child Support/ Alimony Check Stub

Workers Compensation

• Award Letter
• Check Stub

*Documents will not be returned unless specifically requested.

Common Questions about the Sliding Fee Scale

Who is considered a family member for determining family size?
Individuals of a household both traditional and non-traditional are considered family. Families are tied together financially.

Who in the household is eligible for the Sliding Fee Discount Program once family size is determined?
Any member of the household listed on the application as legally binding and 19 years of age and older (any child 18 years and younger may be eligible for Medicaid and Child Health Plus) would be eligible to receive the Sliding Fee discounts if eligibility requirements are met.

How often do I need to apply for the Sliding Fee Discount Program?
You must re-apply every year or if there is a change in your current family size or income.

If I do not want to share financial information, am I still eligible for the Sliding Fee Discount Program?
Eligibility for the SFDP is largely determined by your financial situation. If you choose not to provide your local RPCN Community Health Center with this information, you will be selected as “Self Pay” status and will be responsible for charges in total for all services during any visit to RPCN.

If I am eligible for Medicare, but unable to afford the cost of Medicare, am I eligible for the SFDP?
Yes. Patients insured by Medicare are eligible for Sliding Fee Discounts to their copayments and deductibles.

If I am self-employed or have income from a business how is my income determined and what forms of documentation do I need to submit to apply for the SFDP?
If you are self‐employed or own a business, proper documentation would include your State and Federal tax return. The line on the tax return labeled as “Adjusted Gross Income” is used to determine income. We would also ask for all supporting schedules as well.

If I am self-employed or own my own business and my Sliding Fee Discount Program is set to expire before April 15 th of the year and/or if I will be filing for an extension on my tax return, what do I need provide for documentation to apply for my SFDP?

• If you are due to have your income verified between January 1 st and April 15 th and have not yet completed your tax return, we will ask you to sign a declaration of income that you will report on your tax return. A declaration of income is a form where you document what you get paid, how you get paid, how often, and name of your employer
• We will extend your Sliding Fee Discount Program eligibility until April 15 th , and you will submit your tax return to RPCN once it is completed.
• If the amount you reported in your declaration of estimated income is different from the tax return you submitted to the IRS, you will be responsible to pay for any differences in that change—or you will be credited if we overcharged you.
• If it is after April 15 th and you are filing for an extension on your tax return, you will also be required to submit a copy of the extension form filed with the IRS.
• We will extend your SFDP eligibility for 30 days based on your declaration of income and you must provide documentation within those 30 days to remain eligible.
• If the amount you reported in your declaration of estimated income is different from your tax return submitted to the IRS, you will be responsible to pay for any differences in that change—or you will be credited if we overcharged you.