Billing Information

No one will be denied access to services due to inability to pay. There is a discounted/sliding fee schedule available based on family size and income.

Billing Notices of the Arkadelphia Clinic for Children and Young Adults, PA

Your insurance that you provide will be billed for services rendered at this location.
Co-pays will be required at the time of service unless other arrangements have been made.
Payments made by debit or credit card will have a 3% service fee. This fee will not exceed $3.00.
If you have an outstanding balance, you will be asked to make a payment on this balance. This payment may be made in full or a partial payment may be made
You have the right to speak to someone about your bill. This normally can happen same day, but may need to be at a later date depending on staff availability.
Cash prices for uninsured and underinsured patients are available upon request.
If you are experiencing financial hardship and having difficulty paying your medical bills, we can set up a payment plan that works for your budget.
If your income falls below limits in relation to the federal poverty guidelines, you may be entitled to discounted cash rates for services. No one will be denied access to services due to inability to pay, and there is a discounted/sliding fee schedule available based on family size and income. You must fill out the application to apply for these discounted rates. Your eligibility for discounted rates will not be determined by your race, color, religion, sex, citizenship status, national origin, age, or disability. It will be solely determined by income and household size.

Sliding Fee Schedule

Discounts apply to medical services only. Laboratory, radiology, vaccines, or medications may be billed separately.

Application and Renewal

Patients must reapply annually, or sooner if income changes.
Staff are trained to assist with the application in a private, respectful manner.

Communication

A sign is posted in the lobby notifying patients of the SFDP in English and Spanish.
This policy is available on our website and at the front desk.

Non-Discrimination

Discounts are offered regardless of race, religion, national origin, gender, sexual orientation, or disability.

Income Self-Attestation

Patient Full Name (print): ____________________________________________________________________

DOB: _______________________________

Please fill this out if you are unable to provide proof of income or insurance eligibility *

Did you have any family members in your household who contributed income to your household in the past year? Please list the number of persons in your household and the total monthly income amount combined.

Number of persons: ____________ Monthly Income Amount: $ ______________

I, ____________________________________________ hereby verify that I do not receive any income or am unable to provide proof of income (reason unable to provide: _______________________________________________________________________________________ ) from any of the following sources:

· Wages from employment (including commissions, fees, tips, bonuses, etc.)

· Income from operation of business, self-employed or other employed status

· Rental income from real or personal property

· Interest or dividends from assets

· Social security payments, annuities, insurance policies, retirement funds, pensions, SSI (supplemental security income), or death benefits

· Unemployment or disability payments

· Public assistance payments

· Regular monthly payments received from family or friends

· Any other sources not mentioned above

I understand I must report any changes to my income or assets to ACFCAYA during my next visit. I understand I forfeit my right to be eligible to receive services at a discounted rate if I provide any false statements or information.

Signed: ___________________________________________ Date: _______________________________

*This form expires 1 year after signature date

PROOF OF INCOME VERIFICATION TYPE

(New proof of income must be presented every 12 months)

EARNED INCOME FROM EMPLOYER (PERMANENT OF TEMPORARY):

One pay stub:

Must show gross earnings and number of hours worked (copy of the actual check is not acceptable because it doesn’t show gross income)
Must be dated for current or prior month.

Letter from Employer:

Must show gross earnings, number of hours, and dated from current or prior month.
Must be signed by employer with contact information.

Most recent W2 or Income Tax return (pay stubs preferred, may be more current).

SELF-EMPLOYED:

Most recent Income Tax return.
If no tax return has been filed, Extension Form.

UNEMPLOYMENT OR DISABILITY:

One check stub must be dated from current or prior month.
Award letter must be dated from current calendar year.

PUBLIC ASSISTANCE

Recent Public Assistance application including financial information.