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Sliding Fee Scale

Sliding Fee Discount Program

To qualify for the Charles Drew Health Center, Inc. (CDHC) Sliding Fee Discount Program, you must fill out a Financial Assistance Application, reporting household size and gross annual income for household.

Your family size includes:

  • Patient applying
  • Spouse/Partner
  • Any children being supported in your household
  • Anyone who is included on patient’s federal income tax return

Bring in one of the following to report gross annual income:

  • Pay stubs (from the past 60 days)
  • W-2 form
  • Unemployment statement
  • Disability/Social Security papers
  • Letter from employer
  • Proof of No Income Worksheet

All fees are due at the time of your visit. If you are not able to pay your fee at the time of your medical visit, you will need to speak with a Patient Financial Services Advocate to make arrangements for payment. If you are unable to pay your fee at the time of your dental visit, you will be asked to reschedule your appointment for a later date.

Family Size

100%

125%

150%

175%

200%

>200%

1

$11,880

$14,850

$17,820

$20,790

$23,760

 

2

$16,020

$20,025

$24,030

$28,035

$32,040

 
3

$20,160

$25,200

$30,240

$35,280

$40,320

 
4

$24,300

$30,375

$36,450

$42,525

$48,600

 
5

$28,440

$35,550

$42,660

$49,770

$56,880

 
6

$32,580

$40,725

$48,870

$57,015

$65,160

 
7

$36,730

$45,913

$55,095

$64,278

$73,460

 
8

$40,890

$51,113

$61,335

$71,558

$81,780

 

Visit Fee

$35

$50

$55

$60

$65

$80

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