Sliding Fee Scale Discount Program
Health First provides services to all patients, regardless of their ability to pay. To assist patients who may have difficulty paying, Health First offers a sliding scale discount program for our uninsured and under-insured patients who meet the federal eligibility guidelines. Fees are determined based on income and household size as shown in the chart below.
Please use the buttons below to fill out the Sliding Fee Application online or to download the application.
After clicking the button to fill out the online application, enter your name and email address and click Begin Signing.
Online Sliding Fee Application
Download and Print Application
¿Hablas español? Por favor, utilice este enlace para llenar el formulario en español.
Descargar e imprimir la solicitud
Proof of Income
Proof of income is required for all household members over the age of 18 to determine which sliding fee scale will be assigned to each patient.
You must provide at least one of the following:
- Prior year W-2
- Two most recent pay stubs.
- Letter from employer stating patient’s income. Health First would prefer document be on letterhead and must include employer’s name, address and phone number.
- Form 4506-T (if W-2 not filed)
- Form 1040 or 1040A
- Social security letter for fixed incomes such as social security, disability, pension, etc.
- Free lunch school form, which must include household size and income.
- Most recent unemployment compensation documentation.
- Letter of reference on letterhead from any 501(c) non-profit organizations such as homeless shelters or churches.
- Letter from the patient’s medical provider stating patient is unable to work due to health condition, surgery, etc.
- Self-employed are required to submit detail of the most recent 3 months of income and expenses for the business.
If approved, Health First will send you a card identifying your assigned slide class. Please show the slide card to the receptionist at each visit. The outreach specialist(s) will work with medical staff, pharmaceutical companies and local community resources to help provide medical and social needs (as needed). Outreach specialist(s) may utilize information from your application and income verification for enrollment in additional assistance programs. We will contact you in writing if you are denied for any reason.
Medication Assistance
Are you struggling to afford your medications? Health First may be able to help. We partner with community pharmacies and pharmaceutical companies to offer medication assistance to eligible patients. To see if you qualify or for more information contact the Outreach Department at 1-877-667-7017.
Text Us
Patients may text proof of income documents to our outreach department at 270-873-4162 from their mobile device.
