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Katahdin Valley Health Center
2015 Sliding Fee Application
You may be eligible for a sliding fee discount for medical and dental
services– even if you have insurance.
30 Houlton Street
PO Box 500
Patten, ME 04765
Phone: 1-866-366-5842
Fax: 207-528-2880
Our sliding fee discount, which is based on household income, is available to all KVHC
patients that qualify.
Please take the time to complete and sign the sliding fee application. Your Sliding Fee Application must be completed within 30 days. If supporting documentation is not received within that
time frame a new application will need to be completed. Please be aware we require two forms
of financial information for each adult in the household.
If you filed a 2014 Federal Income Tax return we are required to have a signed copy on file.
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Signed 2014 Federal Income Tax Return with W-2 forms attached. (Both signatures are required if filed jointly)
Please submit any pertinent schedules, such as scheduled C, D, E, or F.
If you do not have your 2014 taxes, you can request a copy of the return transcript
by calling the IRS at 1-800-829-1040 or online at: http://www.irs.gov/Individuals/
Get-Transcript
Please provide a second form of income documentation for each adult in the household.
If you are not required to file income taxes, please submit two of the following documents as
proof of income:
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Three months of bank statements showing direct deposit of income.
Annual Social Security Benefit Statement. (If you do not have a benefit statement, you can
request a copy by calling Social Security at 1-800-772-1213.)
Employment paystubs for the last four weeks.
Unemployment Statement.
TANF Statement.
If you have any questions regarding the sliding fee application process, please feel free to contact our Eligibility Department at 1-866-366-5842 extension 325.
Katahdin Valley Health Center provides community accessible,
quality healthcare with compassion and dignity.
Katahdin Valley Health Center
2015 Sliding Fee Application
You will be required to provide proof of income in order to qualify for the sliding fee.
Please check the appropriate box. Medical Patient 
Dental Patient  Both 
Name:________________________________________________ Date Of Birth:__________________________
Mailing Address: __________________________City_________________ State ___________Zip____________
Are you a United States citizen?___________ Are all members of your household U.S. citizens’?_____________
Phone:____________________________________
Health Insurance:________________________________
Place of Birth City: _________________State: ____________________Country:__________________________
Employment Status (Check One):
 Full-Time
 Part-Time
 Retired
 Disabled
 Student
 Unemployed
Do you need help paying for
prescriptions?
 Yes  No
Please choose from the following:
 I have filed my federal income tax return. If return filed:  Single or  Joint
 I was not required to file federal income taxes for 2014.
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Household Information
Any person living in your household, other than yourself, must be listed below. Please list all dependents, the
sliding fee is based on your household income and your family size.
A Dependant is any person living in your household which you supply at least 50% of their support or income,
and that you claim on your income tax return.
Name
Date of Birth
Insurance
Medical/Dental ID #:
Office Use Only
Spouse _________________________ ___________________ _______________
___________________
Other/Child______________________ ___________________ _______________
___________________
Other/Child______________________ ___________________ _______________
___________________
Other/Child________________ ___________________ _______________
___________________
I attest that all of the information on this application, including annual gross income are complete and accurate to
the best of my knowledge.
Signature__________________________________________
Office Use Only:
Medical Patient ID
__________________
Date _____________________
Dental Patient ID
Slide Level
Annual/90
________________
___________
__________
Change in Income
____________________
MEDICAL SLIDING FEE SCHEDULE
EFFECTIVE MAY 1, 2015
Nominal Charge
100% and Below
125%
Federal Income Guidelines
150%
175%
Family Size
$10.00
A
$20.00
B
$35.00
C
1
$0 - $11,770
$11,771 – 14,712
2
$0 - $15,930
3
200%
Over 200%
$45.00
D
$50.00
E
Full Charge
$14,713 - $17,655
$17,656 - $20,598
$20,599 -$23,540
$23,541
$15,931 - $19,912
$19,913 - $23,895
$23,896 - $27,877
$27,878 - $31,860
$31,861
$0 - $20,090
$20,091 - $25,112
$25,113 - $30,135
$30,136 - $35,157
$35,158 - $40,180
$40,181
4
$0 - $24,250
$24,251 - $30,312
$30,313 - $36,375
$36,376 - $42,437
$42,438 - $48,500
$48,501
5
$0 - $28,410
$28,411 - $35,512
$35,513 - $42,615
$42,616 - $49,717
$49,718 - $56,820
$56,821
6
$0 - $32,570
$32,571 - $40,712
$40,713 - $48,855
$48,856 - $56,997
$56,998 - $65,140
$65,141
7
$0 - $36,730
$36,731 - $45,912
$45,913 - $55,095
$55,096 - $64,277
$64,278 - $73,460
$73,461
8
$0 - $40,890
$40,891 - $51,112
$51,113 - $61,335
$61,336 - $71,557
$71,558 - $81,780
$81,781
NOTE– FOR FAMILIES WITH MORE THAN 8 MEMBERS, ADD $4,160.00 FOR EACH ADDITIONAL MEMBER.
**Certain items provided within a visit(s) cannot be discounted; these include but are not limited to:
Select Adult Vaccines, Injected Medications, Durable Medical Equipment or supplies and Physical Therapy Aids
PAYMENTS MUST BE MADE AT TIME OF VISIT
DENTAL SLIDING FEE SCHEDULE
Based on eligibility, the patient is responsible for the percentage listed of the total charge.
For example: approved slide A, Diagnostic Visit if $90 (A= 20% X 90.00= $18 patient responsibility)
Payor
DIAGNOSTIC AND
PREVENTATIVE
Exams, Cleanings, Sealants
BASIC
Restorative, Periodontal
Treatment
MAJOR
Surgery, Endodontics,
Prosthodontics
A
B
C
D
20%
40%
60%
75%
35%
50%
65%
80%
50%
60%
70%
80%
E
Over 200%
of poverty–
full charge
80%
90%
90%
100%
100%
100%
DIAGNOSTIC AND PREVENTATIVE procedures include: exams, cleanings, x-rays, and sealants.
BASIC procedures include: fillings such as with amalgam (silver) or composite (white) and any gum treatments such as scaling and root planning (deep cleaning).
MAJOR procedures include: any extractions, root canals, crowns, bridges, partials and dentures.
Some dental procedures have a set price such as night guards and any cosmetic procedures.