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Sliding Fee Discount Program
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Oregon Primary Care Association

Sliding Fee Discount Program

SouthRiver Community Health Center is a private, non-profit health clinic which provides quality and affordable medical services. All patients may apply for a sliding scale discount based on their family/household size and net income, with payment arrangements easily made. No one is turned away due to a lack of funds.

For those patients with private insurance, Oregon Health Plan, or Medicare, we will bill directly as a courtesy to our patients. All patients will receive a monthly statement if there is a balance owed on their account. All balances are due within 30 days of the statement date. If you are unable to pay your balance in full, please call SRCHC’s billing department at 541-492-4550 to make payment arrangements.

To be considered for this program you need to complete an application and submit acceptable proof of income for all family/household members. If you have no proof of income within your family/household, you may submit a Self Attestation of Income form which you may obtain from a front desk receptionist or our billing department. If you do not supply adequate proof of income or you do not qualify based on the proof of income received, you will be responsible for the full charges.

You will be expected to pay your portion of the visit at check in for each visit.

Acceptable Proof of Income:

  • Copies of the last 3 months of pay stubs
  • A copy of your unemployment verification, if you are receiving unemployment
  • A copy of your most recent federal tax return
  • Copies of other documents to verify income, such as letters from Social Security or disability services
  • Copies of food stamp verification, if you receive food stamps
  • If you have no income, a letter that explains your means of living or a completed Self Attestation of Income form (available upon request)

Services Included In The Sliding Scale Discount Program

Not all services are eligible for the sliding fee discount. Below are SouthRiver services included in the slide. You will be 100% responsible for the balance due on services not included.

Medical/Behavioral Health Services

  • Office Visits
  • Preventive Exams
  • Medically necessary in-office procedures
  • EKG
  • Breathing Tests
  • Behavioral health office visits

NOTE: Drug Screens, Vaccines, Lesion Removal/Destruction, Sports Physicals and Medications/Supplies are among the NON-COVERED SERVICES

© 2013 SouthRiver Community Health Center | 671 SW Main, Winston, Oregon 97496 | 541-492-4550