Sliding Fee Scale Guidelines

1. Eligibility for the William Bee Ririe Hospital and Rural Health Clinic (WBRH/RHC) Sliding Fee Scale is dependent on the number of people in your family and your family income.

2. Please fill out the Sliding Fee Scale Application.  Sign and date the application and return it with proof of income to WBRH/RHC Patient Financial Service Representative.

3. PROOF OF INCOME – We need current paycheck stubs or a letter from the company/person that you work for that reflects one month’s income for ALL applicable household members.  If you or any applicable household member receives any other source of income, please provide that information as well.

4. Below are some examples of other income that you will need to provide:

• Copy of Federal income tax return

• Social Security, VA Benefits

• Pension, Retirement

• Public Assistance

• Unemployment

• Disability Income, Workers Compensation

• Child Support, Alimony

• Unemployed (Proof of Unemployment form must be completed)

5. The application must be filled out completely, signed, dated, attach proof of income and returned to the billing office within 5 business days.

6. All Co-Payments are required at the time of your office visit.

7. All applicants MUST REQUALIFY annually.

8. The Sliding Fee Scale will be reviewed and modified in accordance with the institution’s fiscal accounting system.

9. Records of all qualified applicants will be maintained in the WBRH/RHC billing office.

10. If we determine you do not qualify for the Sliding Fee Scale or you have not provided proof of income and or proof of unemployment, you will be responsible for the full billed amount.

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