Sliding Fee Scale

As a Federally Qualified Health Center, Dahl Memorial Clinic is able to offer patients a Sliding Discount on most clinic services based on household size and gross income.

To apply, submit a completed application along with last year's tax return or your most recent two pay stubs (showing one month's gross income.) You have 60 days from the date of your appointment to turn in the Sliding Fee Scale Application in order to receive a reduction of charges for that visit.

Patients on the Sliding Fee Scale are expected to make at least a $20 payment each visit to the clinic.

Sliding Fee Scale FAQ

  1. I have health insurance, can I still apply for the sliding scale? Yes. If you qualify, the discount will be applied to any balance that insurance doesn’t cover.
  2. Do I need to bring my paystubs when I come in for my appointment? If you have them- great! bring them. If you don’t, you have 60 days from the date of your visit to turn in your paystubs or tax return.
  3. I applied for the sliding fee scale last summer when I was working here. Do I have to do it again this year?  Yes, the sliding fee scale discount is valid for the stated duration of employment (for seasonal workers) or 12 months from the date of the first covered visit (for year-round workers). After this expiration you must reapply even if your financial circumstances haven’t changed in order to continue receiving the discount.
  4. I live with my boy/girlfriend. Do they and their income count as part of my “household”?  It depends. Your household is defined as yourself, spouse, and your dependent family or all people in your residence with whom you are pooling resources and therefore would be recognized as a family.
  5. I have roommates for the summer. Are they part of my household? No, you do not need to include them on your application.
  6. I work 6 months out of the year.  How is my income determined for the sliding fee scale? Income is determined by multiplying your gross monthly wages by the number of months you will be working. Or you can provide your prior year’s tax return. Your application will be valid only for the 6 months you are working if you provide paystubs. If you provide your tax return, your discount will be valid for one year.
  7. I am not a US citizen.  Can I still apply for the sliding fee scale?  Yes, anyone can apply.
  8. Can I apply for the sliding fee scale AFTER a clinic visit? Yes, you have 60 days from the date of your first visit to turn in your application.
  9. What services are covered under the sliding fee scale? In general: your office visit, some dental services, physical therapy, x-rays, ultrasounds and lab tests (that are processed at the clinic), as well as any medications dispensed at the clinic.
  10. Are dental visits covered? Yes! Dental exams, x-rays, cleanings, and fillings are covered under the sliding fee scale when performed at Dahl Memorial Clinic. You must be on the sliding fee scale at the time of service to receive a discount and you must pay full price for any other dental service received other than those listed above.
  11.  What services are not covered? Office visits with some visiting providers, laboratory tests sent to an external lab, some medical equipment, and a few special order medications and vaccinations may not be covered in the sliding fee program. In addition, Pre-employment and CDL/DOT physicals and Alcohol Drug Information School (ADIS) sessions are always excluded from Sliding Adjustments. Patients will be notified in advance of any uncovered charges.
  12. If I am currently unemployed but expect to be working soon, how is my annual income determined?  Please provide documentation of your unemployment compensation. This will be considered for a 30 day approval on the Sliding Fee Scale. Your documentation and a completed application must be received within seven days of your appointment. You will need to reapply once you begin working again.
  13. I am currently unemployed and have no income. What can I do?  We will accept a letter to the Executive Director stating the reason why you have no income and when you expect to be employed. This will be considered for a 30 day approval at the nominal level on the sliding fee scale. Your letter must be received within seven days of your appointment.  After 30 days, you will need to reapply with a new letter or documentation of income.
  14. I own my own business, what financial documentation will I need? Please provide your most recently filed 1040 tax form including all attachments. Your gross business income before deductions and expenses is used to determine eligibility for this program.  If your business is incorporated and you pay yourself a salary, please provide only your personal tax return showing your compensation.