Family Medicine Clinic in Falls City

It is a discount offered to self pay patients depending on household income and size. A sliding fee schedule is used to calculate the basic discount, using the Federal poverty guidelines. Once approved, we will honor the discount until June 1st. Patients must re-apply for the discount at that time.

You may apply for the Sliding Fee Program by submitting the following:

• Completing and signing the Sliding Fee Program Application (which can be emailed, faxed or mailed before your appointment)
• Providing Proof of Income
• Income is defined as any money received, whether cash, check, or direct deposit used to support your household. Income can include; wages, unemployment, pension, social security, disability, child sup- port, or public assistance such as food stamps or energy assistance.
• Households claiming zero income will be required to talk to Jessie or Penny and fill out a Declaration of No Income form.

The application and documentation can be:

• Dropped off at Family Medicine or Humboldt Family Medicine
• Mailed to Family Medicine at 3307 Barada Street Falls City, NE 68355
• Faxed to 402-245-6651
• Or emailed to pcaudle@cmcfc.org

Once received, a member of our staff will review your completed application, who will then contact you regarding your eligibility.

Please note:

All documentation MUST be received within one week of your appointment in order to process your application. Submitting incomplete or partial information will delay a decision until additional requested information is received. If information is not returned within one week, you are responsible for 100% of all charges. Your approved sliding fee payment must be paid at the time of each visit.

If approved, your office visit and any covered services will be provide at a reduced cost. This can vary from $25 to $40 based on your income.

The discount will apply to all in-office services provided by Family Medicine health care providers. Medication samples will be provided, when available, without charge. The discount applies to office visits, in-house laboratory, and EKG services.

X-rays, injectable medications, outside laboratory tests, and consulting radiology interpretations are excluded.

The discount is not applied to elective procedures, vaccines, OB care, birth control, purchased medications, out-of-office referred care (emergency room, hospital care, specialty care) and diagnostic tests such as CAT scans and MRIs, workman’s compensation or motor vehicle accidents.

• Personal Information (personal ID or driver’s license)
• Payment (cash, checks, and cards accepted)
• Completed and signed Sliding Fee Program Application
• Proof of All Income for Household
  • Last years Income Tax Return – Most Recent Pay Check Stubs – Any other income including social security disability, net business or self-employment alimony, child support, military unemployment, or food stamps energy assistance.