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Sliding Fee Policy

Please review the information below should you be interested in participating in our sliding fee schedule at our practice.

Purpose: To make comprehensive primary care services available and accessible to uninsured and under-insured patients by establishing fees that are affordable to them and in accordance with federal regulations.

Policy: A Sliding Fee Discount Program will be provided to eligible individuals on the basis of their ability to pay. The ability to pay will be determined by the household annual income and family size. Only individuals living in households with income below 200% of the Federal Poverty Level will qualify for the Sliding Fee Discount.

Front Desk Personnel (FD) and Billing Department (BD) Attachments:

  • Registration Form & Instructions Packet – to be provided to all qualified applicants

  • Signage – to be posted in the Front Desk areas

  • Template Letter of Approval/Template Letter of Denial – to be mailed to applicant

  • Sliding Fee Schedule – disclose in Registration Form as well


  1. As part of the registration process, Front Desk Personnel (FD) will determine whether the applicant is covered under a health insurance plan. If the applicant is uninsured, he/she will be informed of the availability of the Sliding Fee Discount and forwarded to the billing department for determination and completion of preliminary application. A determination will be made at the time of service for a discounted fee. The applicant will be required to complete an official application along with proof of income before their next visit to continue receiving the arranged discount.

  2. Individuals interested in applying for the discount must provide the following forms of written verification of household income and size:

    1. One-month paycheck stub or written statement from employer(s), most recent if employed

    2. Last year’s income tax return

    3. Unemployment check stub (if applicable)

    4. Last month’s Social Security check stub (if applicable)

    5. Letter of determination from public assistance programs

    6. Self-declaration of all assets

    7. Some other proof of income

  3. Once the applicant completes the Sliding Fee Discount Application and return it to North Florida Pediatrics Billing Department, it will be reviewed and an approval for the continuation of the discounted fee will be made by the Billing Department.

  4. Upon approval, income and other information will be entered in EPM, and a letter of approval will be sent to the applicant stating the approved discount rate and North Florida Pediatrics’ rights to re-certify income at any given time. Otherwise, if denied a letter of denial will be sent to the applicant clearly stating the reason for denial.

  5. Paperwork filings will be kept in the billing office and patient status in the EPM will be converted to ACTIVE-SFS.

For any questions or concerns, please contact us at (386) 758-0003.

Approved by Samuel Santelices, M.D. (President/CEO) as of 08/06/2018.

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