Income EligibilityHealth Resources and Services Administration

Urban Family Practice Participates

Am I Eligible?

Information on eligibility for low-cost or no-cost health care. HRSA is the primary Federal agency for improving access to health care services for people who are uninsured, isolated, or medically vulnerable.

Click here to see our payment policy and other terms of service


HRSA Fee Schedule

NOTICE TO PATIENTS

This practice serves all patients regardless of inability to pay. Discounts for essential services are offered based on family size and income. For more information, ask at the front desk. Thank you.

AVISO PARA PACIENTES

Esta pr ctica sirve a todos los pacientes, independientemente de la incapacidad de pago. Descuentos para los servicios esenciales son ofrecidos dependiendo de tama o de la familia y de los ingresos. Usted puede solicitar un descuento en la recepcin. Gracias.

For more information about HRSA, please visit their website: http://www.hrsa.gov

Sliding Fee Discount Application

It is the policy of Urban Family Practice, PC, to provide essetial services regardless of the patient's ability to pay. Discounts are offered based on family size and annual income. Please complete the following information and return to the front desk to determine if you or members of your family are eligible for a discount.

The discount will apply to all services received at this clinic, but not those services or equipment that are purchased from outside, including reference laboratory testing, drugs, and x-ray interpretation by a consulting radiologist, and other such services. This form must be completed every 12 months or if your financial situation changes.


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CONTACT INFORMATION

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SPOUSE AND DEPENDENTS

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ANNUAL HOUSEHOLD INCOME

Employment Income

Gross wages, salaries, tips, etc.
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Other Employment Income

Income from business, self-employment and dependents.
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Other Income

Unemployment compensation, workers' compensation, social security, supplemental security income, public assistance, veterans' payments, survivor benefits, pension or retirement income.
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Miscellaneous Income

Interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources.
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NOTE: Copies of tax returns, pay stubs or other information verifying income may be required before a discount is approved.
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ADDITIONAL INFORMATION

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