KVHC Sliding Fees
Click Here to Download KVHC Sliding Fee Application (PDF)
2011 Medical Sliding Fee Scale
2011 Dental Sliding Fee Scale
You may be eligible for a sliding fee discount—even if you have insurance!
Our sliding fee discount which is based on household income is available to all KVHC patients. Please see the financial guidelines on the back of the attached sliding fee application.
Please take the time to complete the sliding fee application and sign page two of the application. We require the following information be submitted in the current week to determine your eligibility for the sliding fee discount:
- Signed 2010 Federal Income Tax Return (If you do not have your 2010 taxes, you can request a copy of the return transcript by calling the IRS at 1-800-829-1040 or online at http://www.irs.gov/individuals/article/0,,id=110571,00.html
OR
If you are not required to file income taxes, please submit one of the following documents as proof of income:
- 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.)
- Four consecutive current pay stubs
- Social Security Checks
- Unemployment Statement
- Three months of bank statements showing direct deposit of income.
- TANF Statement
If you have any questions regarding the sliding fee application process, please feel free to contact our office at 1-866-366-5842 extension 325 for Patten, Millinocket, or Island Falls patients or extension 107 for Houlton patients.
