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 (Downloadable from the Forms page) along with last year's tax return or your most recent two pay stubs (showing one month's gross income.) Your Sliding Fee Scale Application, and all supporting documentation must be turned in at or before the time of your appointment 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. 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.

  3. 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 financial resources and therefore would be recognized as a family.

  4. I have roommates for the summer. Are they part of my household? No, you do not need to include them on your application.

  5. 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.

  6. I am not a US citizen. Can I still apply for the sliding fee scale? Yes, anyone can apply. We will still need to see proof of your income which will be considered in the US dollar equivalent.

  7. What services are covered under the sliding fee scale? Your office visit, behavioral health visits, dental visits, physical therapy, x-rays, ultrasounds and lab tests (that are processed at the clinic), as well as any medications dispensed at the clinic. (See table on page 1.)

  8. Does the sliding fee scale cover services performed at other clinics/hospitals? No. The Dahl Memorial Clinic sliding fee scale only covers services performed at Dahl Memorial Clinic.

  9. What services are not covered? Office visits billed directly by 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 (required by employer) and Alcohol Drug Information School (ADIS) sessions and Return to Duty (court directed) are not covered in the Sliding Fee Discount Program. Patients will be notified in advance of any uncovered charges.

  10. 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. You will need to reapply when you begin working again.

  11. 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. After 30 days, you will need to reapply with a new letter or documentation of income.

  12. 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.

    If you have any other questions that are not answered here, please ask a Dahl Memorial Clinic Representative and we’ll be happy to go over the program in more detail.