219 Health Network
219 Health Network
219 Health Network
219 Health Network
Sliiding Fee Scale 219 Health Network Indiana

Sliding Fee Scale

At 219 Health Network, we understand that quality healthcare should be accessible to all, regardless of financial circumstances. That’s why we offer a Sliding Fee Scale program to ensure that individuals and families receive the care they need at a cost that fits their budget. Through this program, eligible patients can receive discounted rates for medical services based on their income and household size. Our goal is to remove barriers to healthcare access and promote the well-being of our community by providing affordable and high-quality medical care to everyone who walks through our doors.

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Apply for Sliding Fee Scale

Applicant Information

Employment Information

Please list all dependents claimed on Tax Return or would be claimed. Birth certificates required, if taxes were not filed.

The information stated in the application is an accurate and complete statement of my financial status. I understand that willful falsification and/or omission of information in this application will result in denial. I have declared all sources of income as requested.



I understand that I must re-apply for the sliding fee discount program every 12 months and I agree that it is my responsibility to notify 219 Health Network of any changes in annual income, family size and other circumstances anytime during the approved year. I also understand that if I/we do not agree with any decision regarding this application, we have the right to request the application and the decision be reviewed by 219 Health Networks Chief Executive Officer or his/her designee.

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