Discount Program Information Packet

We believe that everyone has a right to quality, affordable health care and have developed a Discount Program to ensure that access to medical care is available to all who use our facilities, regardless of their financial situation and ability to pay.

What is it?
The Discount Program provides reduced fees for the following services:

• On-site Medical Visits
• On-site Procedures
• On-site Behavioral Health Visits
• On-site X-ray Services
• Assistance with prescription costs at our East Jordan & Bellaire on-site Pharmacies
• Laboratory Services (through arrangement with LabCorp)
• Optometric Exams (through arrangement with Dr. Voci)
• Dental Services (through Dental Clinics North)

Who is it for?
All patients and families who are established with Health Center providers and who qualify based on income and family size.

How do I Apply?

1. Complete the application on page 2.
2. Provide evidence of your present income for all family members. Examples of income include:
   • Three most recent and consecutive pay stubs
   • Child support ordered
   • Most recent Social Security Award Letter (Received each year in December)
   • Land contract payments received
   • Monthly pension statement or most recent 1099
   • Unemployment benefit determination statement
   • Worker’s Compensation checks
   • Most recent Federal tax return - W-2’s not accepted
3. Mail or return to the address shown on the back of this application.