Sliding fee program
Oak Orchard Health offers patients a discount on services based on family size and annual income, known as a sliding fee.
How to apply
To get started, download, print, and fill out the application form. Make sure you sign and date it.
Must include your name, current address, including city, state, zip and current phone number including area code. A cell phone number will be helpful, if we have to get in touch with you.
You’ll need to list all sources of household income, both taxable and nontaxable for you, your spouse, and dependents. This income includes (but is not limited to):
|Wages and Tips
Social Security Benefits (net amount after deductions for Medicare)
State Unemployment Insurance
Small Business Corporation Income
Must include all family members living in your household and who you may claim as a dependent when filing your tax return, their dates of birth and any health insurance they have.
Other documents we’ll need for your application:
- A copy of page 1 and 2 of the most recent federal tax return filed AND
- If you are currently working, we need four (4) most current pay stubs that list your name, employer, pay period (weekly, bi‐weekly, monthly), gross wages hours worked, wage rate, etc.
- If you get paid in cash, we need a signed letter from your employer stating your hourly wage rate, number of hours worked and the pay period covered.
- If you are self‐employed or have farm income, we need a copy of the schedule “C” “Profit or Loss from Business” and/or “F” “Profit or Loss from Farming” that was filed with your tax return. If your application is submitted after June 30th of the current year, we will also need a written estimate of your anticipated net income for the current year.
- If you have rental income, we need a copy of schedule “E” “Supplemental Income and Loss” that was filed with your tax return.
- If you are a shareholder of a “small business corporation” and receive compensation and/or taxable income from this corporation, we need a copy of the “K‐l” and schedule “E” Supplemental Income and Loss that was filed with your tax return.
- If your only source of income is Social Security Benefits and/or Pension Benefits and you do not file a tax return, we need a copy of the statement you receive at the beginning of the year stating what your monthly benefits will be. If you get your benefits directly deposited to your account, we will need a copy of the bank statement showing such deposits.
- If you are receiving alimony and/or child support payments, we need a copy of the court document or a letter from who you are receiving these payments stating the amount paid and how often the payments are made and who the payments are for.
- If you are unemployed and collect unemployment insurance, we need to have documentation from unemployment insurance as to what your benefits are, weekly rate and when they began.
- If you have no income at all, we need a signed statement from you stating how you are being supported.
After we receive your properly completed application and required documents, your application will be processed.
Call 585‐637‐3905 ext. 221
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