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DiV. OF MATERNAL AND CHILD HEALTH SLIDING FEE 'SCALF <br />MONTHLY GROSS INCOME <br />FOR USE IN FAHILY PLANNING AND MCH CLINICS <br /> <br /> CABAPRUS COUNTY HEALTH DEPARTMENT <br /> <br />FAMILY PLANNING PROGRAM FEE SCALE - (GROSS INCOME) <br /> <br />100% OF FAMILY ZERO PAY TWENTY PERCENT FORTY PERCENT <br />POVERTY SIZE PAY PAY <br /> <br /> S581 1 $0 TO $581 $582 TO $726 $727 TO $871 <br /> $786 2 $0 TO $786 $787 TO $982 $983 TO $1179 <br /> $991 3 $0 TO $991 $992 TO $1239 $1240 TO $1486 <br /> $1196 4' $0 TO $1196 $1197 TO $1495 $1496 TO $1794 <br /> $1401 5 $0 TO $1401 $1402 TO $1751 $17S2 TO $2101 <br /> $1606 6 $0 TO $1606 $1607 TO $2007 $2008 'TO S2409 <br /> $1811 7 $0 TO $1811 $1812 TO $2264 $2265 TO $2716 <br /> $2016 8 $0 TO $2016 $2017 TO $2520 $2521 TO $3024 <br /> $2221 9 $0 TO $2221 $2222 TO $2776 $2777 TO $3331 <br /> $2426 10 $0 TO $2426 $2427 TO $3032 $3033 TO 13639 <br /> $2631 11 $0 TO S2631 $2632 TO $3289 $3290 TO $3946 <br /> $2836 12 $0 TO $2836 $2837 TO $35&$ $3546 TO $4254 <br /> <br /> SIXTY PERCENT EIGHTY PERCENT FULL PAY <br /> PAY PAY BEGINS <br /> <br />$872 TO $1016 $1017 TO $1161 $1162 <br />$1180 TO $1375 $1376 TO $1571 $1572 <br />$1487 TO $1734 51735 TO $1981 $1982 <br />$1795 TO $2093 $2094 TO $2391 $2392 <br />$2102 TO $2451 $2452 TO $2801 $2802 <br />$2410 TO $2810 $2811 TO' $3211 $3212 <br />$2717 TO $3169 $3170 TO $3621 $3622 <br />$3025 TO $3528 $3529 TO $4031 $4032 <br />$3332 TO $3886 $3887 TO $4441 $4442 <br />$3640 TO $4245 $4246 TO $4851 $4852 <br />$3947 TO $4b04 $4605 TO $5261 $5262 <br />$4255 TO $4963 $4964 TO $5671 $5672 <br /> <br />INSTRUCTIONS: AFTER DETERMINING SLIDING SCALE PAY CATEGORY, FIND DOLLAR <br /> <br />NOTE: NO CHARGES MAY BE ASSESSED IF PATIENT IS MEDICAID ELIGIBLE. IF <br /> SCALE. ANNUALIZED MONTHLY INCOME FIGURES MAY NOT EQUAL THOSE ON <br /> <br />DIV. OF MCH <br />5114/93 <br /> <br />AMOUNT OF CHARGE ON APPROPRIATE SCHEDULE. <br /> <br />YEARLY INCOME IS KNOWW, USE ANNUAL <br />ANNUAL SCALE DUE TO ROUNDING. <br /> <br />SCHEDULE OF PATIENT (SELF-PAY OR PRIVATE PAY) CHARGES <br />WOMEN'S PREVENTIVE HEALTH SERVICES (FAMILIY PLANNING) <br /> <br />Service <br /> <br />Complete Physical (Initial or physical) <br />Extended Revisit (Revisit <br /> <br />Limited Revisit (Revisit w/o pelvic} <br />Natural Family Planning (NFP Servl=es) <br />Horplant Insertion <br /> <br />Norplant Removal <br /> <br />Norplant Removal/Reineertion <br /> <br />DepO Provera Injection <br /> <br />03-16-92: Approved by Board of Commissioners <br />08-03-92: Approved by Board of commissioners <br />12-O7-92: Approved by Board of Commissioners <br /> <br />~O% pay 40% pay. 60% Pay 80% Pay Ful% pay <br />$ 19.00 $ 38.00 $ 56.00 $ 75.00 $ 94.00 <br />$ 8.00 $ 16.00 $ 23.00 $ 31.00 $ 39.00 <br />$ 4.00 $ 9.00 $ 13.OO $ 18.OO $ 22.00 <br />$ 8.00 $ 16.OO $ 24.00 $ 32.OO $ 40.00 <br />$101.00 $202.00 $304.00 $405.00 $506.00 <br />$ 25.00 $ 50.00 $ 75.00 $1OO.OO $125.OO <br />$121.00 $242.00 $364.00 $485.00 $606.00 <br />$ 5.00 $ 10.00 $ 16.00 $ 21.00 $ 26.00 <br /> <br /> <br />