Thank you for your interest in the Rubicon Healthcare Sliding Fee Program.

This program aims to help individuals, both insured and uninsured, lower their out-of-pocket medical and dental expenses. To be eligible, you must present proof of your household income. For those visiting one of our clinics for the first time, Rubicon Healthcare permits income to be self-declared during the visit to prevent any delay in care. Nevertheless, providing documentation will be necessary to receive a fee reduction for any subsequent visits.

To apply for a sliding fee discount, please carefully follow the instructions below, complete the attached application in full, and include all required documentation. You may be eligible for retroactive fee reductions for services received before your application date, provided proper documentation is submitted. The amount of your discount is based on the Federal Poverty Guidelines, with minimum office visit fees set at $20 for medical services and $35 for dental services.

STEP 1: FILL OUT THE SLIDING FEE APPLICATION

Please remember to include all household members and sign your application.

STEP 2: PROVIDE PROOF OF YOUR INCOME

Please provide one of the following documents for ALL members of your household (related and unrelated) to show household income:

  • Two most recent paystubs

  • Current Tax Return

  • Current W-2s from all employment

  • Bank Statements showing all activity for the last three months

  • Social Security or Unemployment Award Letter

  • Amounts received in public assistance (rental assistance or food stamps, etc.) or a signed Release of Information

If you do not receive income from any source please provide one of the following:

  • Letter from a government office explaining the benefits you do or do not qualify for (unemployment office or social security office, etc.).

  • Denial letter for an application of benefits (must be dated within the last 3 months).

  • Anyone claiming to have no income but lacks a documented explanation will be required to reapply and submit a completed sliding fee application each visit.

STEP 3: RETURN YOUR SLIDING FEE APPLICATION

Along with the supporting documentation, to the front desk of our Citrus County Rural Health center or you may mail it to:

STEP 4: PAY YOUR CO-PAY OR FEES FOR TODAY’S OFFICE VISIT

The Billing Department will process your application and send you a letter in the mail explaining whether or not you qualify based on your application.

If additional documentation is needed they will contact you by telephone or mail. Please allow up to 30 days for processing your application after it is received.

 

Should it be determined that you do not meet the criteria for our sliding fee program, you will be accountable for any costs not covered by your insurance. If you are found to qualify for our sliding fee program, a credit will be issued if you have overpaid for your clinic visit and have no other outstanding bills or past bad debt with Rubicon Healthcare.

Notice: If you had no income last month and plan to self-attest today, please complete this application at the clinic when you have your appointment. If you are providing income verification, kindly proceed with filling out the form below.

Source includes earnings, unemployment compensation, worker’s compensation, social security, supplemental security income, public assistance, veterans’ payments, survivor benefits, pension or retirement income, interest, dividends, rents, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources. (Maximum of 10 uploads/256mb each)

I, the undersigned, have completed this application for Sliding Fee eligibility and confirm that this information is true and correct, to the best of my knowledge. I further understand that should my economic situation change, I am solely responsible to report that upon my next visit. All information I provided within this application, including my self-attestation statement is truthful, correct and is subject to confirmation by Citrus County Rural Health, Inc. Any false statement or perceived attempt to deceive may result in a denial for sliding fee benefits and the balance associated with it would be my responsibility.