Sliding Fee Scale
Our mission at Coal Country Community Health Center is to create access to affordable high quality preventative and primary care for all, especially medically under-served populations. CCCHC offers a sliding fee scale to all income eligible patients based on annual household income for services rendered at CCCHC as well as dental visits and pharmacy services at participating dental clinics and pharmacies.
The Sliding Fee Scale program, based on family income, may reduce your costs by 20%, 40%, 60%, 80% and up to 100%. You may qualify with or without commercial health insurance, including Medicare and Medicaid. Patients are required to pay a $10 Nominal Fee on office visits, due at the time of the visit, before the SFS discount is applied.
How does the SFS Program Work?
The SFS program provides discounts for patients with an income below 200% of the federal poverty guideline. A minimal co-pay is required and payable at the time of service. Charges will be sent to commercial insurance, if applicable, and the SFS discount will be applied to the remaining balance. Some exclusions may apply; please visit with the Eligibility Coordinator for more information.
How do I Apply for the SFS Program?
Patients interested in applying for the SFS program will schedule a confidential consultation with the Eligibility Coordinator to enroll in the program. All information is kept confidential. Proof of income is required for all wage-earners who live in your household. Please bring a copy of your last two paystubs, unemployment, or current tax statement. You will also need to bring your current insurance information, including any insurance cards. Non-income applicants must have a third party sign to verify unemployment or income status.
Patients must re-apply annually for the SFS program. Discounts are not valid on charges or appointments with a visiting provider. Other exclusions may apply.
If you have questions regarding the sliding fee scale program or would like to schedule an appointment, please contact Megan, CCCHC Eligibility Coordinator, at (701) 873-4445.
Sliding Fee Scale Application
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Megan SorensenAcceptable Forms of Income Verification
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- Most recent Federal tax return
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- IRS form W-2 or 1099
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- 2 recent paystubs
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- Social Security, disability, or pension benefit statements
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- Child support and/or alimony verification
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- Income verification from employer
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- Unemployment Benefits
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- Patients with no income must complete a Non-Income Verification Form