Sliding Scale Information

and Application

 

Pecos Valley Medical Center (PVMC) is a Federally Qualified Health Center (FQHC) and, therefore, receives state and federal funding to reduce fees for medical and dental services to eligible patients and families.  Any reduction is based upon where your income fits within the Federal Poverty Guidelines issued each year by Congress.  Please note, PVMC is not able to reduce costs for medications, lab, or x-ray costs.

 

In order to determine your eligibility for this program, we need you to provide us with all the information requested on the attached form.  AND, we need you to complete the application as soon as possible or within 10 work days of the time of your visit.  If you can not get all the information together within that time, you must call 505-757-6482 and tell us when you will be in to complete it.

 

Just like all of your medical and dental health information, all your financial information is kept totally confidential.

 

Once we have determined you are eligible for the sliding fee and how much your “slide” will be, we will mail you a letter letting you know.  Your eligibility and information will be kept on file for a year.  If your income goes up or down significantly during that year, you must let us know.

 

Because it is important for us to prove to our funders that PVMC has people pay what they can for the services and care they receive, you will be asked to pay your share of the costs of any visit at the time of the visit.  If you do not have the ability to do that, please talk with the patient advocate to set up payment arrangements.

 

Our staff will also review with you whether you are eligible for Medicare, Medicaid or any other pubic insurance that can support a person’s medical and dental care costs.  If you are eligible, they will help you process and submit these applications.

 

If you have questions about the application or what you need to do, please call Jenny, Audra, Jody or Louella at PVMC at 505-757-6482 or Yvette and Jose in Dental at 505-757-6666.

 

Thanks very much for your cooperation and assistance with this process.

 

 

Following is a list of what we need in order to determine what your “income” is:

Earned Income:

1. Copy of your latest Federal or State Income Tax Return;
2. Pay check stubs for at least your last 2 months, showing the name of your employer;
3. Letter from your employer stating how much you are paid, when you get paid, and for how long you have been working for them – letter must have name, address and phone number to contact;
4. Copy of a signed work agreement that states when and how much you are paid.

 

If you are self employed:

1. A copy of your most recent quarter tax reporting form;
2. A copy of your last filed gross receipts report;
3. A financial statement for the last year or a signed Affidavit stating what your income for the last 2 months has been.

 

If you receive monthly income from State or Federal Government:

1. A copy of your award letter or most recent check or deposit notices for:
   • Social Security or VA Benefits
   • Unemployment compensation
   • Worker’s compensation
   • PERA or ERA or other retirement fund payer
   • General Assistance

 

If you receive Child Support or Alimony:

1. A certified copy of your Divorce or Separation Decree, or Court Order;
2. A copy of the check with explanation of how often the amount is received;
3. A Letter from your lawyer, the Child Support Division of HSD, or the person who pays you.

 

Other regular income:

1. A letter from the relative or friend that provides the regular income;
2. A letter or award notice of grant or student loan.

 

If housing cost is more than 60% of reported monthly income, you will have to document how you pay for living expenses.

 

If you have no income of any kind, we will need a letter from the person(s) who support(s) your living arrangements.

 

NOTE:  Letters written and signed by the applicant are not acceptable.  Any letter MUST be dated within the last 30 days and have a name, address and telephone number to reach the person and verify the information if we need to.

 

 

Application

 

To apply for sliding fee scale assistance, download the application form, fill in the requested information, and return the application to Pecos Valley Medical Center in person or by mail.

 

Download the application —

 

As a Microsoft Word document: Click here.

 

As a Rich Text Format document: Click here.

 

As an Adobe PDF document: Click here.

 

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