Sliding Fee Discount Program

Clinica Bienestar’s Sliding Fee Discount Program can significantly reduce the cost of your care. Discounts are based on your household size and gross income (before taxes) and are available to patients without insurance as well as those whose insurance doesn’t fully cover their visit. The program is updated each year using the Federal Poverty Guidelines, and you can apply at any time.

For more information, call us at (866) 590-6411. Your well-being is our top priority, and we are here to serve you.

It is Clinica Bienestar policy to provide essential services regardless of the patient’s ability to pay. Discounts are offered depending upon family income and size. Please complete the following information and return to the front desk to determine if you or members of your family are eligible for a discount.

The discount will apply to all services received at the center but not those services which are purchased from outside, such as reference laboratory testing, drugs, x-ray interpretation by a consulting radiologist, and similar services. In the hope that your economic health improves, discounts apply only to current, not future services. This form must be completed annually and/or if there are any changes. Please inquire at the front desk if you have questions.

Application Form

Applicant Name

First Name Last Name

Number of related persons living in your household

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Cell Phone

MRN#

Include the following information for yourself, your spouse (if applicable) and and dependents under the age of 18

Click on the + icon to add a new name

Name

Date of Birth

Income Information
Note: Include income from all related persons in household and income from all sources including gross wages, tips, social security, disability, pensions, annuities, Veteran’s payments, net business or self-employment, alimony, child support, military, unemployment, public aid, and other.

Gross wages, salaries, tips, etc. (Self)

Gross wages, salaries, tips, etc. (Spouse/Other)

Gross wages, salaries, tips, etc. (Total)

Social Security, Pension, annuity, and veteran’s benefits (Self)

Social Security, Pension, annuity, and veteran’s benefits (Spouse/Other)

Social Security, Pension, annuity, and veteran’s benefits (Total)

Alimony, child support, military family allotments (Self)

Alimony, child support, military family allotments (Spouse/Other)

Alimony, child support, military family allotments (Total)

Income from business, self-employment, and dependents (Self)

Income from business, self-employment, and dependents (Spouse/Other)

Income from business, self-employment, and dependents (Total)

Rent, interest, dividend, and other income (Self)

Rent, interest, dividend, and other income (Spouse/Other)

Rent, interest, dividend, and other income (Total)

Total Income

Please upload the following: 1) Government Issued ID, 2) Prior year tax return, three most recent pay stubs, or other, and 3) Insurance card(s), applicable only if insured by 3rd Party

Drop files here or

Accepted file types: jpg, pdf, Max. file size: 256 MB, Max. files: 3.

Verification Checklist

Identification/Address: Government Issued ID

Income: Prior year tax return, three most recent pay stubs, or other

Insurance: Insurance card(s), applicable only if insured by 3rd Party

I certify that the family size and income information shown above is correct. Copies of tax returns, pay stubs, and other information verifying income may be required before a discount is approved.

Self-Declaration of Income

I, the undersigned, declare that I have been working and receiving cash payments in the amount of:

Dollar Amount

Frequency (day, week, bi-weekly, monthly)

Name of Employer

Income Declarations

I declare that I have no check stubs or other documentation to prove my earnings.

I declare that I am unemployed and do not have any income at this time.

I understand that any falsification or failure to report any income or changes in income may result in my being ineligible for the sliding fee scale adjustment to my charges for services.

Date of Signature

2026 Sliding Fee Discount Schedule

Learn More About Paying for Care

Application Form

2026 Sliding Fee Discount Schedule

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