What income documentation is accepted?

Accepted income documentation includes: most recent federal tax return (Form 1040), recent pay stubs (last 30 days), Social Security or SSI benefit letter, pension or retirement income statement, unemployment benefit award letter, or written statement from employer. If you cannot provide documentation, a signed self-attestation statement is accepted.

What are the discount levels?

Discounts are based on your household income as a percentage of the Federal Poverty Level (FPL). Level A provides 100% discount, Level B provides 75% discount for 101-133% FPL, Level C provides 50% discount for 134-150% FPL, Level D provides 25% discount for 151-200% FPL, and Level E provides 0% discount.

Sliding Fee Schedule | Hopscotch Primary Care

Discount Tiers

Five levels of assistance, based on income

Discounts are based on your household income as a percentage of the Federal Poverty Level (FPL). The application includes up-to-date income thresholds by household size.

Level A

100%

At or below 100% FPL
Full discount applied

Level B

75%

101% – 133% FPL

Level C

50%

134% – 150% FPL

Level D

25%

151% – 200% FPL

Level E

Above 200% FPL
Full fee applies

Ready to apply?

See if you qualify

Income thresholds are based on the current Federal Poverty Level guidelines. The application includes up-to-date thresholds by household size to help you determine your discount level.

If you have Medicare or another insurance: The sliding fee discount applies to your out-of-pocket costs — your copay, coinsurance, or deductible. It does not affect what your insurer pays. You may still qualify for a discount even if you are insured.

Apply for the Sliding Fee Discount Program →

Application Process

How to apply for the Sliding Fee Discount Program

The process is simple and confidential. You can apply at any time — before your first visit, at your appointment, or when your financial situation changes.

Let us know

Tell the front desk staff you'd like to apply for the sliding fee discount program. There's no judgment — this is what the program is for.

Complete the form

Fill out a short application with your household size and annual income. Staff will help you if needed. Translation assistance is available.

Provide documentation

Share income documentation if you have it. If you don't, a signed self-attestation statement is accepted — no documentation required.

Discount applied

Your discount level is determined on the spot and applied to all qualifying charges from the date of approval. Valid for 12 months.

Accepted income documentation

Most recent federal tax return (Form 1040)
Recent pay stubs (last 30 days)
Social Security or SSI benefit letter
Pension or retirement income statement
Unemployment benefit award letter
Written statement from employer

Can't provide documentation?

No problem. If you cannot provide income documents, you may sign a self-attestation statement at the front desk. We will not deny assistance based on inability to provide paperwork.

If you need help completing the application, staff will assist you. Language assistance is available at all locations.

Renewal reminder: Your discount is valid for 12 months. You'll be asked to re-apply annually. If your income or family size changes significantly during the year, notify your clinic so your discount level can be updated.

Sliding Fee Schedule

Five levels of assistance, based on income

See if you qualify

How to apply for the Sliding Fee Discount Program

Let us know

Complete the form

Provide documentation

Discount applied

Accepted income documentation

Can't provide documentation?

Patients

Company

resources

LEGAL