It is the policy of MERCY MEDICAL to provide essential services regardless of the patient’s ability to pay. Discounts are offered based on family size and annual income based on the federal poverty guidelines. Please complete the following information and return to the front desk to determine if you or members of your family are eligible for a discount.
The discount will apply to all services received at this clinic, but not those services or equipment that are purchased from outside, including reference laboratory testing, drugs, x-ray interpretation by a consulting radiologist, and other such services. This form must be completed every 12 months or if your financial situation changes.

All patients of Mercy Medical Health Services are eligible to apply for the sliding fee discount program, SFDP. Our program will allow us to discount your services based on your income and family size. The discount is valid for 12 months. Annually we will ask you to verify your income and family size. Our SFDP is optional for all patients, if you decline all fees will apply. We accept the following payment methods:

• Private Insurance
• HMO
• PPO
• Medicaid/Medicare
• Credit/Debit Cards
• Cash

To apply for the Sliding Fee Discount Program, patients must supply required documentation, including valid photo identification, proof of income for the past 30 days and current address verification. Patients must be re-certified every six months or sooner.

Acceptable Identification

• Driver’s License
• Passport
• Current College ID Card
• U.S. State-Issued ID Card
• U.S. Immigration Photo ID Card
• Military/Foreign ID Card
• Acceptable Proof of Income
• Check stub(s) from employer equaling the last 30 days of employment
• Disability/Worker’s Compensation Notification Form
• Medicaid/Medicare Form or Card
• Income Tax W2 Form
• Social Security Notification Form
• Unemployment Eligibility Sheet*, Checks or Check Stub
• Veteran’s Benefit Statement
• Child Support Court Award Official Documentation from another Social Services Agency