Sliding Fee Discount Program

Compassionate financial support

Sliding Fee Discount Application

It is the policy of MAHEC to provide FQHC and essential services Medical, Behavioral Health, and Dental Care regardless of the patient’s ability to pay. Discounts are offered based on family size and annual income. Please complete the following information and submit for review to determine if you or members of your family are eligible for a discount.

The discount will apply to all FQHC and essential services provided and billable by MAHEC. Services performed by outside organizations and equipment that is purchased from outside companies, including outside laboratory testing, drugs, and x-ray interpretation by a consulting radiologist, and other such services, will not be covered under this policy. This form must be completed every 12 months or if your financial situation changes

These documents will need to be turned in before your application can be processed:

Completed Application
Proof of Income

Please return all documents to your Patient Financial Advocate within 30 days of your first appointment.

Legal First Name

If insured, this must match first name on insurance, otherwise first name on identification if it differs from the name the patient goes by

Legal Last Name

Middle Initial

Date of Birth

Current MAHEC Patient at (Select all that apply):

Patient Account # (MRN) (If known)

Parent or Legal Guardian Name

Email Address

Phone

Street Address

Apt, suite, unit or floor #

City

State

Zip Code

Spouse or Dependent First Name

Spouse or Dependent Last Name

Date of Birth

Needs Sliding Fee

Current Patient at MAHEC

Add Dependent

Employment Income

Self

Spouse

Other

Last two pay stubs, tax form with schedule C if you are self employed, or letter from employer

Compensation Income

Self

Spouse

Other

Unemployment compensation, workers' compensation, Social Security, Supplemental Security Income, public assistance, veterans' payments, survivor benefits, pension or retirement income

Other Income

Self

Spouse

Other

Interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources

Note: Copies of tax returns, pay stubs, or other information verifying income are required before a discount is approved.

I acknowledge Dental Laboratory costs are exempt from the Sliding Fee Discount

I certify that the family size and income information shown above is correct and acknowledge providing false information will rescind application of the Sliding Fee Discount

Please type your name as your signature

Family Health Centers and Internal Medicine
Phone: (828) 771-3507
Fax: (828) 407-2640
Mailing Address:
123 Hendersonville Rd
Asheville, NC 28803

Ob/Gyn Specialists
Phone: (828) 771-5443
Fax: (828) 407-2639
Mailing Address:
119 Hendersonville Rd
Asheville, NC 28803

Center for Psychiatry and Mental Wellness
Phone: (828) 771-5466
Fax: (828) 820-8327
Mailing Address:
125 Hendersonville Rd
Asheville, NC 28803

Dental Health Centers
Phone: (828) 398-5918
Fax: (828) 552-8691
Mailing Address:
123 Hendersonville Rd
Asheville, NC 28803

Internal Medicine
Phone: (828) 771-5502
Fax: (828) 579-3748
Mailing Address:
123-A Hendersonville Rd
Asheville, NC 28803

Sliding Fee Discount Program

Compassionate financial support

Sliding Fee Discount Application

1 Patient Information

2 Contact Information

3 Spouse and Dependents

4 Annual Household Income for all working adults

Employment Income

Compensation Income

Other Income

5 Signature