Sliding Fee Scale

Samaritan Daytop Village offers a Sliding Fee Scale for patients who do not have the financial means to cover the cost of our services. Eligible patients have:

• Limited or no income
• Limited or no health insurance or Medicare
• High insurance deductible rates
• High Medicare co-insurance

Anyone can apply for a sliding fee scale. The final cost of services to pay for our programs is based on household income and family size (as outlined in the U.S. Department of Health & Human Services Federal Poverty Level Guidelines for Annual Income).

Applying for a Sliding-Fee Scale

You can apply, download, print, and complete our Sliding Fee Scale application form then submit it to your Case Manager. You may also schedule an appointment to complete the application with your Case Manager. (A Spanish language version of this application is available upon request.)

With your application, you must also provide the following:

• One form of government-issued ID
  • Examples include a driver’s license, social security card, state card, military ID, or passport
• Two forms of proof of income
  • Pay stubs
  • Social Security, disability, or pension benefit statements
  • FAFSA form
  • Most recently filed tax return (1040)
  • Unemployment benefits statement

If you have no proof of income, please ask your Case Manager or Patient Navigator how to complete a self-declaration form.