• 1-866-364-1366

Sliding-Fee Scale Program 

HOMETOWN Health Center a Sliding Fee Program for patients that are income eligible.

Sliding Fee Program Secure Application

It is necessary for HOMETOWN Health Center to ask personal questions in order to give you a discount on our medical expenses. This information will be kept on file in our center in strict confidence. You must verify your income once every year at time of application renewal. Your yearly income tax return with a copy (Do not send originals, documents are shredded after 30 days) of your W-2 form, payroll check stubs covering the past month, or copies of your social security checks, or other checks you may receive will be sufficient proof. Your annual income will be used to calculate the level of your payment.

Fields marked with * are required.

(if patient is under 18 years old)