Sliding Fee Scale

Affordable Care Costs Tailored to You

Prism Health North Texas offers an affordable option for your care by having a Sliding Fee Scale. Rates are discounted based on household income and household size.

To qualify for the sliding fee scale, complete an application and submit supporting income documents. Upon submission, a Financial Navigator will review your application and documents to determine your eligibility.

Sliding Fee Scale Application Instructions

1. Download and complete the application. (Download: English / Español)

2. Provide Required Documentation: To determine the appropriate fees for services, please submit documentation that verifies your income for the past month. Fees will vary based on your eligibility, family size, and gross monthly income. Acceptable forms of documentation include:

• • Last year’s income tax return or W-2
  • Pay stubs from the 4 most recent weekly or 2 biweekly pay periods
  • Unemployment check(s)
  • Social Security (SSI) checks or statements
  • Pension checks
  • Proof of alimony, child support, etc.
  • Verification of income by employer
  • Bank statements showing direct deposits

3. Email the application and supporting documentation to: [email protected]

4. Once your application and documents are submitted, a Financial Navigator will review your application and determine your eligibility. They will contact you with an update on your application status.