Sliding Fee Scale

KVHC Sliding Fee Program

Click Here to Download 2017 KVHC Sliding Fee Application (PDF)

As a Federally Qualified Health Center (FQHC), Katahdin Valley Health Center (KVHC) provides a sliding fee discount for all services to patients who meet the eligibility guidelines. Sliding fee discounts are determined according to household size and yearly income, regardless of health insurance status. This program allows patients to pay a set co-pay of $10, $20, $35, $45, or $50 per medical visit, or a certain percentage on their bill at our dental offices if they qualify. savings

How do I qualify for KVHC’s Sliding Fee Discount?

If you wish to qualify for the Sliding Fee Discount you must provide documentation of annual gross income for all household members. Two forms of documentation of income for each household member are required in order to determine eligibility. Please refer to list below for acceptable documentation of income:
  • Signed 2016 Federal Income Tax Return with W-2 forms attached. (Both signatures are required if filed jointly)
  • Please submit any pertinent schedules, such as scheduled C, D, E, or F.
  • If you do not have your 2016 taxes, you can request a copy of the return transcript by calling the IRS at 1-800-829-1040 or online at: https://www.irs.gov/Individuals/Get-Transcript
OR If you are not required to file income taxes, please submit two of the following documents as proof of income:
  • Three recent months of bank statements showing direct deposit of income; most preferred.
  • Annual Social Security Benefit Statement (If you do not have a benefit statement, you can request a copy by calling Social Security at 1-800-772-1213.)
  • Employment paystubs for the last four weeks.
  • Unemployment Statement
  • TANF Statement
  • If you have any questions regarding the sliding fee application process, please feel free to contact our Eligibility Department at 1-866-366-5842 extension 325.