Thomas E. Langley Medical Center Sliding Fee Scale
THOMAS E. LANGLEY MEDICAL CENTER offers a Sliding Scale to those patients who qualify. If you would like to apply for the Sliding Scale, you must bring in Financial Documentation for everyone in your home or dwelling.
The following list is an example of required Financial Documentation as it pertains to you:
* Most recent Income Tax return* Social Security, Disability, and/or VA benefit letter.
* Retirement/Pension Income documentation.
* Last four consecutive pay stubs to include Work Comp and/or Unemployment.
* Food Stamp letter showing the amount of your award.
* TANF (Temporary Assistance for Needy Families) letter showing the award amount.
* Proof of Child Support.
The following financial documentation and/or actions are NOT accepted:
* W-2 forms* Mailing applications and/or documentation
* Faxing applications and/or documentation
* Bank Statements
To view or print the Sliding Scale Application, Please click here (Adobe Acrobat Reader required)
