Sliding Fee Scale Program

To assist our patients with their healthcare needs, Wayne Memorial Community Health Centers (WMCHC) utilizes the federal Sliding Fee Scale program. The Sliding Fee Scale program will be granted to patients who meet the financial criteria under the federal poverty guidelines.

 

You may download a copy of the Sliding Fee Application by clicking on the link below:

 

WMCHC Sliding Fee Application.pdf
 
Please complete the application and return with the supporting documentation of income to;

Wayne Memorial Community Health Centers
Outreach and Enrollment Coordinators
601 Park St.
Honesdale, PA 18431

  • Income Tax Return (most recent, unless income has changed then 2 months paystubs)
  • Social Security Award Letter
  • Unemployment Statement
  • Workman’s Compensation Statement
  • Pension Award Letter
  • Copy SNAP benefit and/or cash assistance letter
     

The application may be dropped off at one of our sites to be forwarded to PPOutreach-Enroll.

 

Upon receipt of the application for processing, you will be contacted for any additional information required to complete the application.

 

If you do not have insurance coverage and you have no income and fall below the poverty guidelines, you will be required to apply for Pennsylvania Medical Assistance prior to Sliding Fee approval. That determination will be made upon receipt of the application. You will be required to pay the minimum co-pay at each office while your application is pending.

 

You will be notified of the status of your application within 10 days of receipt of all income verification requested. If you are approved for the programs, acceptance as a patient is valid at all sites below.

 

Please call 570-251-6569 OR 570-251-6554 with any questions or concerns.



 

 
 
 
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