AG 1994 09 06 - Laserfiche WebLink

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DIF, OF HAYE~NAL AND C~ILD ]{EALII! SLIPING FEE SCALE NONTNLY GROSS INCOME FOR USE IN FAMILY PLANNING AND fI{:l{ CLINICS 100% OF FAMILY ZERO I'AY TWENTY PERCENT FORTY PF. RCENT POVERTY SIZE PAY PAY ADULT WELT.NESS PROGRAM FEE SCALE - (GROSS INCOME) SIXTY PERCENT EICHTY PERCENT FULL PAY PAY PAY BEGINS $613 I $0 TO $613 $614 lO $767 $768 TO $920 5921 $82{2 2 $0 TO $820 $821 TO $102S $1026 TO $1230 $1231 $1027 3 $0 ]'0 $1.27 $1028 TO $)203 $1284 TO $1540 $1541 51233 4 $0 TO $1233 $[23~ TO $t542 $1543 TO $1850 $1851 $1640 5 $O TO $166{) $1461 TO $1n00 $1801 TO $2160 $2161 $1647 6 $0 TO $16t, 7 $1648 TO $2058 $2059 TO $2470 $2471 5185:] 7. $0 IO $1853 $1854 TO $2317 $2318 TO. $2780 $2~81 $2060 8 $0 TO $2O60 $2061 rO $2575 $2576 TO $3090 $309! $2267 9 $0 TO $226~ $2268 TO $2833 $2834 TO $3400 $2473 10 $0 TO $2~73 52474 TO $3092 $3093 TO $3710. $3711 52680 11 $0 TO $2680 $2681 TO $3350 $3351 TO $4020 $4021 $2887 12 $0 TO $2887 $2888 TO $3608 $3609 TO $43~0 INSTRUCTIONS: AFTFR DETERMINING SLIDING SCALE PAY CATEGORY, FIND DOLLAR AMOUNT NOTE: NO CHARGES flAY BE ASSESSED IF PATIENT IS MEDICAID ELIGIBLE. IF YEARLY SCALE. ANNIIALIZED MONTHLY INCOME FIGL"RES HAY NOT EQUAL THOSE ON ANNUAL DIV. OF MCH 6/10194 TO S1073 $1076 TO $1226 51227 TO $L435 $1436 TO $1039 $1640 TO $1797 $1798 TO $2052./ 12053 TO $2158 $2159 TO $24~6' $2467 TO $2520 52521 TO $2879 $2880 TO $2882 $2883 TO 132~2 $3293 TO $3243 $3244 TO $3706 $3707 Tq $3605 $3606 TO $~119 $4120 TO $3967 $3968 TO $4532 $4533 TO $4328 $4329 TO $4946 $4947 TO ,$4690 $4691 TO $5359 $5360 TO $5052 $5053 TO $5772 $5773 OF CHARGE ON APPROPRIATE SCIiEDULE. INCOME IS KNOWN. USE ANNUAL SCALE DUE TO ROUNDING. .2,0% Pay 40% $ 4.00 $' 200 60% Pay 80% Pay Full Pay $12.00 $16.00 $20.00 5-18-~2: App~ed by Board of Commissioners. *x~'i~ (MARGE t~R ~OSE 65 YFARS OF AGE AN} OVfR.