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IPN Rural Health Clinic's Sliding Scale

Iredell Physician Network Rural Health Clinic's Sliding Scale Policy & Procedure

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Iredell Physician Network's Rural Health Clinics (IPN RHC), Harmony Medical Care and Family Care Center of Taylorsville, are dedicated to providing quality health care, health education, and preventive care services to all members of the community regardless of financial barriers (ability to pay) through the regular publication of a sliding  fee scale. Discounts described on the sliding scale will reflect the patients' obligation based on their income in relation to the federal poverty guidelines, published annually. This policy applies to all covered medical and behavioral health patients. IPN RHC will extend the sliding scale to eligible patients who are without a primary health insurance, Medicare Supplement Plan, and patients that have coinsurance out-of-pocket expense from commercial payors.

Procedure Outline:

  1. As part of the registration process, the medical assistant will determine, dependent upon the payor source, whether the patient will have an out-of-pocket payment liability ( uninsured, has Medicare without supplement, or has private insurance with a deductible or co-pay). In these cases, the patient is informed of the availability of the Sliding Fee discount for medical and other IPN RHC services. The patient is given the appropriate eligibility forms for completion to be accepted into the program. All forms must be completed satisfactorily for inclusion in the program.

  2. Eligibility for the Sliding Scale Program is based on gross household size and income.*

  3. Individuals must provide one of the following forms of written verification of household.
    1. 30 days of most recent pay statements
    2. W-2 form (1 accepted)
    3. Last Income Tax Return-1099 Schedule C-Self Employed (1 accepted)
    4. Written statement from employer
    5. Unemployment or Disability Income Statement
      * household is defined as the taxpayer plus his/her dependents; 'income' is defined as income derived from household members.
    6. Child Support Verification Letter
    7. Food Stamp Verification Letter
    8. Recent Bank Statement
    9. Affidavit of Income Form (to be used only if the applicant does not have a written income verification) (Refer to Affidavit Form)

  4. Once the applicant completes, signs, and dates the Sliding Fee Scale Application, the medical assistant will review it for completeness, sign as a witness, and date it. The medical assistant will also document the income application calculation, slide percentage, and eligibility dates in the financial record of the patient management system (PM). As part of the application process, patients must attest that they do not have valid insurance, Medicare, or Medicaid coverage. This attestation is witnessed by the medical assistant of IPN RHC. Applications and written documents are scanned into the patient's electronic medical record (EMR) for retention.

  5. All Sliding Scale applications and income documentation are valid six (6) months from the first visit or after the expiration date indicated on their eligibility card. Patients are required to notify IPN RHC of any changes in their income, employment status, or household size regardless of the time of year that it occurs.

  6. A nominal payment is requested at the time of service for all uninsured patients. IPN RHC's nominal charge is $25 for medical and behavioral visits. IPN RHC's nominal charges are established based on cost of operations, funding availability, and usual & customary fees charged by other local community providers.

  7. Audits are conducted on a monthly basis by the front office supervisor or practice manager on a percentage of self-pay patient charts to ensure policy is being followed and proper documentation is being collected. Written findings will be sent to the IPN RHC Corporate Office.

This policy applies to the two rural health clinics of Iredell Physician Network: Family CareCenter of Taylorsville and Harmony Medical Care.

*See also: 2021 Federal Poverty Guidelines from: