AG 1995 08 21 - Laserfiche WebLink

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FOR ~JSE IN FAMILY PLANNING AND HOt! CLINICS / I /PROGRA~ FEE SCALE - (GROSS MATERNAL HEALTH I I IiNCOME~ 100% OF FAMILY ZERO PAY TWENTY PERCENT FORTY PERCENT SIXTY PERCENT EIGHTY PERCENT FULL PAY POVERTY SIZE PAY PAY PAY PAY BEGINS 5623 1 SO,TO $623 $624 TO $778 $779 TO $934 $935 TO $1089 $1090 TO $1244 $1245 $836 2 $0 TO $836 $837 TO $1045 $/046 TO $1254 $1255 TO $1463 $1464 TO $1671 $1672 $1049 3 $0 TO $1049 $1050 TO $1311 $1312 TO $1574 $1575 TO $1836 11837 TO $2097 12098 $1263 4 SO.TO $1263 $1264 TO $1578 $1579 TO $1894 $1895 TO $2209 $2210 TO $2524 $2525 $1476 5 $0 TO $1476 $1477 TO $1845 $1846 TO $2214 $22i5 TO $2583 $2584 TO $29~1 $2952 $1689 6 $0 TO $1689 $1690 TO $211] $2112 TO $2534 $2535 bO $2956 $2957 TO $3377 $3378 $1903 7 $0 TO $1903 $190~ TO $2378 $2379 TO. $2854 $2855 TO 33329 $3330 TO $380& $3805 $2116 8 $0 T0.$2116 $2117 TO $2645 $2646 TO S317& $3175 TO S3703 $3744 TO $4231 $4232 $2329 9 $0 TO $2329 $2330 TO $2911 $2912 TO $3494 $3495 TO $4076 $4077 TO $4657 $4658 $2543 10 $0 TO $2543 $2544 TO $3178 $3179 TO $3814 $3815 TO $4449 $4450 TO $5084 $5085 $2756 ll $0 TO $2756 $2757 TO $3445 $3~46 TO $4134 $4135 TO $4823 $4824 TO $5511 $5512 $2969 12 $0 TO $2969 $2970 TO $3711 $3712 TO $4~54 $4455 TO $5196 $5197 TO $5937 $5938 INSTRUCTIONS: AFTER DETEFJ4INING SLIDING SCALE PAY CATEGORY, FIND DOLLAR AMOUNT OF CHARGE ON APPROPRIATE SCHEDULE. NOTE: NO CHARGES MAY BE ASSESSED IF PATIENT I$ ~ED~CAIO ELIGIBLE. If' ~EARL/ INCOME IS KNOWN. USE ANNUAL · SCALE. A~NUALIZEO MONTMLY INCOME FIGURES P~Y NOT EQUAL TNOSE ON ANNUAL SCALE DUE TO ROUNDINg. DIV. OF Service ~0Z ~ay 60Z Pay $0Z P,a¥ Full Pay Complete (initial visit) $~7.11 $34.22 $51.34 $68.45 $85.56 ~evisit (subsequent visit) $17.~1 $34.22 $51.34 $68.45 $85.56 Rhogam (for Rh negative pts.) $ 8.05 $16.09 $24.~4 $32.18 $40.23 Non-Stress Fetal Test tS 8.00 $16.00 $24.00 $32.00 $40.00 Oral Glucose Tolerance Test $ 4.00 $ 8.00 $12.00 $16.O0 $20.00 20Z Pay Eligibility wili b~ dote&-minad with each p~ognancy. Income will b~ determined by daclarartion of income Patients will ba ~.92[P_~ted to pay according to th~ above fee =ar~ with a subse~ent pregnancy will h~ referred to the program .upervieor or nursing director prior to acceptance for Patlg~ts with hoepital ineura~ce will bu ~eferred'to ~rlYate care. If tho patient l~ unable to obtain medical care ~lthin cabarru# County (l..., lack of up-Ir.oat funde, owes doctor for pra¥1ou~ doctors' appointments ~illed).patient can receive care at the Cabarr~s CoUnty ~ealth Department.. In.urancu.pa~l~nt. will bu placed in tho full category rmgardle~ of income. In.uranc~ will health department. O6-17m91: Approved by cabarru. County Board of Health and County Co~i..ioner~, to bu .ffecltve O7-OI-91- 08-04-92~ Approved by Cabarru. County ~oard of Health a~d Count~ Co~l~sioners' 08-03-92. 0g-06~94: Approved by Coungy Co~issioners to be effective 07-01-9A.