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tIONTHLY GROSS INCOHE FOR USE {N FA~{ILY PLANNING AND HC{I CLINICS [ { I [ %RRI OUN{ ,EAI~ )EP,~ :N'i'I MATERNAL HEAL~' PROGRAM FEE SCALE - (GROSS INCOME) 100% OF FAHILY ZERO PAY TWENTY PERCENT FORTY PERCENT SIXTY PERCENT EIGHTY PERCENT FULL PAY POV ER'F~ SIZE PAY PAY PAY PAY REG1 NS 5613 1 / 50 20 5c, 13 561~ 30 5767 5768 TO $920 5921 TO 51.073 51074 TO 51226 51227 S820 2 $0 TO 5820 ~821 10 51025 $1026 T0 S1230 S1231 TO 51&35 S1436 TO 51639 5L640 51027 3 S0 3'O 51O27 51028 TO S)283 $128~ TO {1540 S154J TO S1797 S1798 TO {2052 ,'/ {2053 11~40 5 10 TO $le,/,O 114/,1 TO SlaO0 $1801 TO 52160 12161 TO $2520 52521 TO 52879 52880 $16~,7 6 $0 TO 51~,/,7 $1648 TO $2058 52059 TO S2470 $2471 TO 52882 $2883 TO $3292 53293 51852{ 7 S0 TO S1~33 ~1854 TO S2:117 52318 TO $2780 52~81 TO S3243 53244 TO 53706 53707 $2060 8 {o TO {2060 {2061 ~O $2575 S2576 TO 53090 $309i TO S3605 {3606 TO 54119 54i20 S2267 9 $0 TO 52207 52268 TO 52~33 52834 TO 53400 $~401 TO 53967 53968 TO 5~532 5~533 52~73 I0 50 ~O 52q73 52~7~ TrJ 53092 53093 TO $3710 $3711 TO 5432B 54329 TO $~9~6 54947 52080 11 50 TO 52680 $2681 TO 53350 {3351 TO S4020 54021 TO {4690 $4691 TO {5359 {5360 S2887 12 $0 TO ~2887 ~2888 TO 53608 $3609 TO S~330 S4331 TO S5052 55053 TO 55772 55773 INSTRUCTIONS: A["T{<R DETF. RMINING SLIDING SCALE PAY CATEGORY, FIND DOLLAR AHOUHT OF CHARGE ON APPROPRIATE SCHEDULE. NOTE: NO CHARGES MAY BE ASSESSED IF PATIENT IS HEDICAID ELIGIBLE. IF YEARLY INCOME I5 KNOWN, USE ANNUAL SCALE. ANNHALIZ£D HONTHLY INCOME FIGURES MAY NOT E~UAL THOSE ON ANNUAL SCALE DUE TO ROUNDINO. DIV. OF HCH 611019& Service 20% P. ay 40% Pay 60Z Pay 80% Pay Full Pay Complete (initi~visit) $15.84 $31.68 $47.52 $63.36 $79.20 Revisit (subsequent visit) $15.84 $31.68 $47.52 $63.36 $79.20 Rhogam (for Rh negative pts.) $ 9.28 $18.55 $27.83 $37.10 $46.38 Non-Stress Fetal Test $12.00 $24.00 $35.00 $47.00 $59.00 Oral Glucose Tolerance Test $ 4.00 $ 8.00 $12.00 $16.00 $20.00 Eligibility will be determined with each p~egnancy. Incomo will be determined by declarartion of incom. by patient; however, verification can be requested at the discretion of the eligibility .pe¢ialist. Patients will be expected to pay according to the above fee scalo0 Patients on sliding fee scale who fail to pay during a pregnancy and return to the health department for care with a subsequent pregnancy wall he referred to the program supervisor or nursing director prior to acceptance fo~ care. Patients with hospital insurance will be ~eferred to private care. If the patient I. unable to obtain medical care within Cabarrus County (i.e., lack of up-front funds, owes doctor for previous services, doctor.' appointments filled) patient can receive care at the Cabarrus County Health Department. In.urance patients will be placed in the full category regardless of income. Insurance will be filed by hoal~h department. 06-17-91: Approved by Cabarrus County Board of Health and County Commissioners, to be effecitve 07-01-91. O8-O4-92~ Approved by Cabarrus County Soard of }~ealth and County Com~lssioners O8-O3-92. 07-06-93: App~v~ by Co~ty Ommissi0ners.