Sliding Fee Scale

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The Angel Harvey Family Health Center of the Infant Welfare Society of Chicago offers financial help for medical, dental, optometry and behavioral health counseling to qualifying patients who are uninsured or underinsured and have low income.

How do I qualify?

To qualify for the sliding fee scale, you must bring proof of your “household” gross annual income.

A “household” includes legal children, a civil union partner or married spouse, and legal dependents.

Annual gross income includes salary, unemployment benefits, disability or social security benefits, investment income or other sources of income that support the household.

You should bring proof of all of the household income for yourself and everyone in your household. The following documents are can be used for proof of income for each member of the household:

  • Most recent tax return
  • 2 most recent pay stubs from employer for bi-weekly payments or
  • 4 most recent pay stubs from employer for weekly payments
  • Most recent W-2 or 1099
  • Letter from employer stating cash earnings that is on letterhead or notarized and signed by your employer or supervisor
  • Letter from the Social Security Administration documenting your SSI or SSDI benefits
  • Letter from the Social Security Administration documenting that you are ineligible for government benefits
  • Letter detailing unemployment benefits from your state unemployment office
  • Military Leave and earnings statement
  • Notarized letter stating you have no source of income signed by you

How do I apply?

To apply for sliding fee payments, bring proof of household income to your appointment (see above).

Click here for sliding fee application

HOUSEHOLD:

A “household” includes legal children, a civil union partner or married spouse, and legal dependents. Please list the name of individuals in your household and relation to you.