Patient Information
SMC offers several sliding fee discounts on our services base on household income and family size.
As a Federally Qualified Community Health Center, we are required to obtain all of the following information for our records.
If the required eligibility information is not available at time of visit, patient will be triaged by a clinician to determine medical condition. If clinician determines patient must be seen, patient will be seen and then payment arrangement will be made for the visit. If clinician determines that patient does not need to be seen on that day, we will offer patient an appointment within the next 48 hours or require patient to pay $80.00 toward the office visit. Patient will have (7) seven days to bring the required information. Once received, patient might be entitled to a refund, which will be processed within (5) five business days.
Patients with Insurance, Medicare or Medicaid
(Bring the following documents at each visit)
- Photo ID
- Insurance Card
Sliding Fee Scale Eligible
(Bring the following documents at each visit)
2. Proof of Identification:
Current Photo ID (if no photo id, see front desk clerk for Affidavit)
2. Proof of Income
(Only one of the following is required):
a. Minimum of two current paycheck stubs and proof of income for all in your household (or notarized letter from your employer) or
b. Income Tax Return or W2 Form (most recent) or
c. Disability/Worker’s Compensation Notification Form or Social Security Notification Form or Pension/ Retirement Statement or Veteran’s Benefits Statement or Child Support Court Award (must include amount of benefits) or
d. Current Food Stamp Summary or
e. Other documents showing proof of income (such as letter of reference from one the following: Employer, Minister/Priest, etc. on a company or official letterhead)
Proof of Family Size
(Only one of the following is required):
a. Prior year’s Income Tax Return (most recent) or
b. Any decision letters indicating that the patient has legal responsibility for the child, such as, court order guardianship papers or custody papers or
c. Birth Certificate for each child age 18 and younger
All patients must be recertified annually or at 1st visit after March 1st every year
Self-Employed Persons
(Bring the following documents once a year or 1st visit after March 1st)
- Current Photo ID (if no photo id, see front desk clerk for Affidavit)
- Most recent federal tax return to verify income and unemployment insurance wage determination from the Georgia Dept. of Labor
Unemployed Persons
(Bring the following documents once a year or 1st visit after March 1st)
- Current Photo ID (if no photo id, see front desk clerk for Affidavit)
- Unemployment insurance wage determination from the Georgia Dept. of Labor and the most recent federal tax return to verify income and/or a current 30-day separation notice
Homeless
(Bring the following documents once a year or 1st visit after March 1st)
- Current Photo ID (if no photo id, see front desk clerk for Affidavit)
- Patient will be asked to sign a Certification for Homeless Form to certify present situation. (see front desk clerk for form)
No Documents Available
(Bring the following documents once a year or 1st visit after March 1st)
- Current Photo ID (if no photo id, see front desk clerk for Affidavit)
- Patient will be asked to sign a Self Attestation of Income Form to certify present situation. (see front desk clerk for form)
Notes
Pharmacy – SMC provides prescription drugs at a sliding fee rate to patients, and discounts dispensing fees based on the patient sliding fee discount eligibility. Nominal Charge patients will only pay a flat $6, inclusive of dispensing fee. The remaining sliding fee scale eligible patients, Plan A (25%), Plan B (50%) and Plan C (75%), will pay for prescription drugs at cost plus a dispensing fee of $8, $10 and $12 respectively.
Eyeglasses – Eyeglasses are charged separately from Optometry visits. The cost of eyeglasses to eligible sliding fee scale patients start at $49 for single vision, $69 for bifocal and $129 for progressive.
Podiatry – Supplies (such as inserts, insoles and orthotics) are charged separate from Podiatry visits.
Labs – SMC provides labs services by an outside company. The cost of the lab services is eligible for a sliding fee scale as well.
All patients must be recertified annually or at 1st visit after March 1st every year
