Please download and fill out the form before your next visit. If you don’t have a way to print it, you can always pass by one of our locations and request a printed version from our Front Desk Team Members; they will be more than happy to serve you.
Por favor descarge su forma y llenela antes de la fecha de su visita, si usted no posee un metodo para imprimirla, pase por una de nuestras oficinas y solicite una forma impresa a una miembro de de nuestras recepcionistas medicas que hable español, ellas le ayudarán.
WE ARE RURAL HEALTH CERTIFIED CLINICS
To make comprehensive primary care services available and accessible to uninsured or underinsured patients, we established fees that are affordable to them, in accordance with federal regulations. North Florida Pediatrics will offer a Sliding Fee Discount Program to all who are unable to pay for their services. North Florida Pediatrics will base program eligibility on a person’s ability to pay. The ability to pay will be determined by the household’s annual income and family size. Our company will not discriminate based on an individual’s race, color, sex, national origin, disability, religion, age, sexual orientation, or gender identity. The Federal Poverty Guidelines are used in creating and annually updating the sliding fee schedule to determine eligibility.
The following guidelines apply to the Sliding Fee Discount Program.
Notification: North Florida Pediatrics will notify patients of the Sliding Fee Discount Program by:Â
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Notification of the Sliding Fee Discount Program will be offered to each patient who reports no Insurance upon admission or is underinsured.
- North Florida Pediatrics posts a notice about the sliding-fee discount program in the clinic waiting area and on our website’s Locations & Providers pages.
Requests for discounted services must be made by the patient’s parent or Legal Guardian. The Sliding Fee Discount Program will only be made available for clinic visit fees. Information and forms can be obtained here in PDF format(to be downloaded and printed before your appointment), or you may request them at any time from the Front Desk Team at all of our Clinics.
 The patient/responsible party (parent or Legal Guardian) must complete the Sliding Fee Discount Program application in its entirety. Staff will be available, as needed, to assist with patient/responsible party applications. By signing the Sliding Fee Discount Program application, persons are confirming their income to North Florida Pediatrics as disclosed on the application form.
 Eligibility:
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 Family is defined as: a group of two people or more (one of whom is the householder) related by birth, marriage, or adoption and residing together; all such people (including related subfamily members) are considered members of one family. North Florida Pediatrics will also accept non-related household members when calculating family size. Income includes: gross wages; salaries; tips; Social Security; Retirement Pension; Child-support; Alimony; other may include: dividends; royalties; income from rental properties, estates, and trusts.
 Those with incomes at or below 100% of poverty will receive our lowest Nominal Fee for health care services. Those with incomes above 100% of poverty, but at or below 200% of poverty, will be charged a nominal fee according to our sliding fee schedule. The sliding fee schedule will be updated during the first quarter of every calendar year, with the latest Federal Poverty Line Guidelines.
The Sliding Fee Discount Program determination will be provided to the applicant(s) in writing, and will include the percentage of Sliding Fee Discount Program write off, or, if applicable, the reason for denial. If the application is approved for less than a 100% discount or denied, North Florida Pediatrics will work with the patient’s parent, Legal Guardian, and/or responsible party to establish payment arrangements.Â
Sliding Fee Discount Program applications cover any balances incurred within 6 months after the approved date (unless their financial situation changes significantly). The applicant has the option to reapply after the 6 months have expired, or anytime there has been a significant change in family income. When the applicant reapplies, the look-back period for proof of income will be only the 30 days before the date of the renewal of the Sliding Fee Discount Program application.