Sliding Fee Scale 2017-11-30T14:59:41+00:00


It is the policy of LK Health to assure that no patient will be denied health care services due to
a patient’s inability to pay for such services. To meet this policy objective LK Health provides a schedule of fees and payment options to uninsured and underinsured patients in the community it serves. This schedule of fees is discounted on a Sliding Fee Scale (SFS) and is available to patients through the Sliding Fee Discount Program (SFDP). It provides primary and preventative care services for all patients that qualify, based on income and family size. LK Health will ensure the protection of patient privacy and confidentiality during this process.

In order to qualify for our Sliding Fee Scale, you will need to provide proof of income at the time of your appointment. All Sliding Fee Scale payments/fees are due at time of service.

The Sliding Fee Scale / Discount Program will be provided to eligible persons based on the client’s ability to pay. Ability to pay is determined by the family/household size and annual gross income relative to the most recent U.S. Department of Health & Human Services Federal Poverty Guidelines (FPG). Patients may use the SFS for Medical, Dental and Behavioral Health Services.

Required Documentation


1. To verify the patient’s gross income, the patient MUST provide proof of income for all household members such as:

  • Payroll: Most current payroll check-stubs. Paid weekly equals four (4) check stubs, paid biweekly equals two (2) check stubs, paid monthly equals one (1) check stub
  • Self-employed: Most recent 1099 form/ income tax returns
  • Award letters of Social Security Income, Social Security benefits, disability benefits, unemployment benefits, etc.
  • Pension or Retirement checks. If the payment is direct deposit, a copy of most recent bank statement indicating the transaction.
  • Cash income with no income proof: A self-affidavit
  • Case contribution from others: in-kind support form
  • Other income including alimony, child support, etc.


1. Patient’s identification must be verified before enrollment into the SFDP (or receiving other services at LK Health)

  • U.S. State issued driver’s license or identification card
  • Passport
  • Other government issued identification

Income Verification Eligibility Period

1. Sliding Fee eligibility is valid for the following periods related to income verification documentation provided:

Income Verification Document Eligibility Period
Self-Attestation: forgot proof of income 1 appointment
Self-Attestation: no income 12 months
Cash Income 12 months
Unemployment Benefits 12 months
Payroll Check Stub 12 months
SDI 12 months
1099 Form (Self-employed) Annual
SSI, SSDI, Pension, Retirement Benefits Annual

Re-Certification of Income

Re-certification of the SFDP is within 30 days or after the income verification expiration date. The eligibility period begins at the time of the first office visit and expires on the last day of the time frame specified in Income Verification Eligibility Period listed above.

Payment At Time of Service

SFDP patients are required to pay for the services at the time of office visit.

Services Not Available Through Sliding Fee Scale

  1. Diagnostic laboratory tests that are sent out for processing (Foundation Laboratory) are not included in the SFDP medical fee. All patients will be charged for these services. These additional items will be charged at checkout.
  2. All forms required for pediatric care will be completed free of charge. Disability and provider letters will be completed with a charge of $25. All other forms will be completed for a $5 fee. Forms will be completed within 5-7 business days.

For additional information call LK Health at (323) 728-8588 and ask to speak to an enrollment counselor.