Discount Fee Program Application
Discount Fee Program Application
The Discount Program assures that patients have access to all services (Medical, Pediatric, OB-GYN, Dental and/or Behavioral Health) regardless of their ability to pay. At the Center, we provide access to quality healthcare regardless of insurance status. We accept most private insurance, Medicaid, FAMIS, Medicare and offer a discount fee program. Eligibility for the discount fee program is based solely on income under Federal Poverty Level guidelines and family size. We encourage you to apply for our Discount Program, which provides qualifying patients with significant discounts for health care services. If you wish to apply for the program, please complete and print all of the forms below prior to your appointment.
- Discount Program Application (English | En Español)
- Income Verification Form - Highlighted for Employer (English | En Español)
- Income Verification Form - Highlighted for Other (English | En Español)
- Statement of Support (English | En Español)
- Discount Fee Program Pre-Screening Checklist (English | En Español)
- Self Declaration of Eligibility for Discount Fee Program (English | Spanish)
- Form 4506-T EZ (Joint Highlighted): Short Form Request for Tax Return Transcript (English)
- Form 4506-T EZ (Individual Highlighted): Short Form Request for Tax Return Transcript (English)
Go to our Patient Forms & Portal page to download registration forms and for a list of items you should bring to every appointment for a faster check-in experience each time you come to the Center.