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La Red Health Center
302.855.1233

Sliding Fee Scale Application

This application helps us determine if you qualify for reduced fees based on your household income. All information provided will be kept confidential and is used solely to assess your eligibility for our sliding fee scale program.

La Red Health Center offers discounted service fees and prescriptions to our patients. We base our sliding-fee scale on federal guidelines regarding income and household size. Use the calculator to quickly find out if you qualify.

$15,650
$19,563
$21,870
$23,475
$27,388
$31,300
$

Medical/Behavioral Health

$30Nominal Fee
$40
$60
$75
$100
100%

GYN (Routine)

$30Nominal Fee
$40
$60
$75
$100
100%

GYN (Specialty)

$100Nominal Fee
60%
80%
90%
100%

Dental (Tier 1)

$50Nominal Fee
60%
80%
90%
100%

Dental (Tier 2)

$100Nominal Fee
60%
80%
90%
100%

Dental (Tier 3)

$250Nominal Fee
60%
80%
90%
100%
Language:

Sliding Fee Scale Application

Valid from March 1, 2023 through February 29, 2024

This application must be completed in its entirety in order to be processed. All questions must be answered.

1

Household Information

List all Dependents

Include all household members (spouse, children, etc.) Check "Patient" if this person is also a patient.

2

Proof of Income

You must bring proof of All Household Income. Please check all that apply:

3

Application Certification

4

Electronic Signature

Please sign below to certify that all information provided is true and accurate. Your signature confirms your agreement to the terms stated above.

Use your mouse, trackpad, or finger to sign above. This signature has the same legal effect as a handwritten signature.