Financial Assistance

NHC defines a family as a group of two or more people living together who are financially supporting one another.

Do not include any family members who do not live with you or family members who are financially independent.

Count up the members of your family. Write that number down.

NHC defines income as an individual’s Adjusted Gross Income (AGI). AGI is your annual income (wages, salaries, tips, etc.) minus standard deductions.
If you have a Form 1040 from last year’s tax returns, use the number listed on the bottom of the first page (11b: Taxable Income). If you have no documentation to reference, use the following formula to estimate your monthly income:

(Hourly Wage x Hours Worked Per Week) x 4 = Monthly Income

Do this for each member of your family who earns a taxable income. If you have any family members earning non-taxable income (i.e. cash), list their income as zero. Children and other family members who do not work? List their income as zero.

Add up the monthly incomes for all family members. Write that number down.

Below is a table displaying the 2021 Federal Poverty Guidelines (FPG) for monthly income.

Remember, only patients reporting a family income at or below 200% poverty will qualify for discounted services.

Columns A through D are eligible for discounted services. Column E must pay in full for charges and will not receive a discount. If you fall under Column E, you are not eligible to participate in the program.

Use the chart to determine what discount you will receive (Category A-D). Here are three examples to help you determine where you land on the discount schedule.

1. Susan is a single mother of two young children. Susan also cares for her mother who lives with her and her children. Susan’s family size is 4. Susan is the only person in her family earning taxable income. Susan earns $2,600 per month. Susan belongs to Discount Category B as her family size is 4 and her monthly income lands between $2,209 and $2,937.
2. Jose is married to his wife Miranda. They have three young children who live with them. Jose earns $2,300 per month at his job. Jose’s wife earns $2,700 per month. Together, the couple earns $5,000 per month in taxable income. Jose’s family size is 5. Jose belongs to Discount Category D as his family size is 5 and his family’s monthly income lands between $4,295 and $5,173.
3. Dan just moved in with his father for a temporary stay. Dan’s father is financially independent and is not sharing any financial responsibilities with Dan. Dan earns $2,000 cash per month at his part-time job. Dan belongs to Discount Category D as his family size is 1 and his monthly income lands between $1,783 and $2,147. Dan does not count his father because Dan’s father is financially independent and the two are not financially supporting one another.

Using the schedule, determine what discount category you belong to (A-D).

Once you figure out what Discount Class you belong to (A-D) discounts vary depending on the service you are using at the time of your appointment. Services are broken into service categories and include three categories: medical, dental, and behavioral health.

With your Discount Category (A-D) in mind, use the chart to determine what your payment will be for your next visit. Here are four examples to help you determine charges.

1. I belong to Discount Class A. I came in today for an appointment to discuss my diabetes with a behaviorist. I am responsible to pay $5 for my visit. The remainder of my charges will be adjusted by NHC so that $5 is my only responsibility.
2. I belong to Discount Category B. I came in today for a medical visit with my medical Doctor. I am responsible to pay $35 for my visit. The remainder of my charges will be adjusted by NHC so that $35 is my only responsibility.
3. I belong to Discount Class C. I came in today for a dental exam and cleaning. The total of these charges was $300. I am responsible to pay 60% of these charges. The remainder of my charges will be adjusted by NHC so that $180 is my only responsibility ($180 = 60% of $300 charges).
4. I belong to Discount Class D. I am diabetic and NHC is going to deliver my insulin medication to my home. My pharmacist told me I will pay a total of $16 for my insulin. This includes the cost for the medication plus the dispensing fee.

You will receive discounted services for 12 full months following approval of your application. A month prior to expiration, NHC will ask you to fill out a new application and provide documentation proving your income. Eligibility will be assessed using the most current Federal Poverty Guidelines.

If your income or family size changes during your 12 months of discounted services, you are responsible to notify NHC and submit a new application. Note: This may result in a greater discount if you’ve added a family member or your household income has decreased.

Download, print, and fill-out an application:

• English
• Español

Return your Application with proof of income to the Front Desk of your NHC Clinic.

Proof of income documentation is required to process your application. For each member of your family reporting a taxable source of income, attach at least one of the following documents to your application:

• Two weeks of most recent pay stubs
• Check stubs from Unemployment Insurance
• Previous year W-2
• Previous year completed tax return
• Government-issued documentation for other non-wage income such as Social Security, Worker’s Comp, Cash Assistance, Child Support, Alimony, Veteran’s Benefits, Retirement, or Pension
• Previous three months of bank statements
• Letter from employer
• If self-employed: prior year tax return or most recent three months of bank statements.

Note: You can still fill out the application without proof of income. NHC will allow you 30 days to return proof. However, no discount will be applied to your account until proof of income documentation is received and your discount is verified.

If you are reporting zero family income, please indicate why. For example, a patient may be working seasonally for an employer that only pays cash, may be experiencing houselessness, or may have been recently let go from their job.