Financial Assistance Program: Sliding-Fee Scale

The CIFC Greater Danbury Community Health Center (GDCHC) offers a sliding fee schedule to provide financial assistance to all patients who qualify based on income, regardless of whether the patient carries health insurance coverage.
 
The CIFC Greater Danbury Community Health Center makes a determination as to a patient's potential eligibility for financial assistance based on the information provided on the patient's intake form. Any patient who indicates that she/he may be income eligible on their intake form is screened by the GDCHC Office Coordinator or designee.
 
Potentially eligible patients are then required to complete the attached form and provide verification of their household income.

The following documentation is required to verify income:

If the individual is paid wages, s/he is required to provide one of the following:

  1. A most recent income tax return; OR
  2. Most recent W2 Form; OR
  3. 2 current, consecutive pay stubs.

If the individual is paid in cash, s/he is required to provide both:

  1. A most recent income tax return, which includes a Schedule C form; AND
  2. A letter from his/her employer, on the employer’s letterhead, stating the employee's hours, days worked, and amount earned weekly.

If the individual is self-employed, s/he is required to provide the following:

  1. A most recent income tax return, which includes a Schedule C form, AND a self attestation letter indicating weekly or monthly income and/or profit and loss statement; OR
  2. Three (3) months worth of bank account statements AND a self attestation letter indicating weekly or monthly income and/or profit and loss statement.

As applicable, these documents shall also serve to verify income in the case of unemployment or disability:

  1. Social Security Income Statement;
  2. SSI Supplemental Security Income Statement;
  3. Disability Income Statement; OR
  4. Unemployment Income Statement.

***All patients deemed eligible for financial assistance must verify their income annually in order to continue to receive financial assistance.***

Greater Danbury Community Health Center 
Sliding-Fee Scale: 3/1/2015

Sliding-Fee Scale