Primary Care Medical Office Visits

A SFDP will be provided to eligible individuals based on their abiltiy to pay.  The ability to pay will be determined by household incomeand family size, relative to a discount schedule based on current federal poverty guidelines (FPG).  Only individuals and families with annual incomes at or below 200 % of the FPG will qualify for the SFDP.  Borinquen Medical Centers  ensures that:

1. No patient is denied care due to inability to pay
2. Fees are consistent with locally prevailing rates or charges
3. SFDP is reviewed and adjusted as needed at least once every 3 years with the approval authority of the governing board.
4. Every reasonable effort to obtain reimbursement from third party payers is made

As part of the registration process, the Patient Service Representative (PSR) will inform patients of the SFDP and explain the paperwork needed to complete the application.  Information about the SFDP is also available in our brochure and Signage throughout our ceters in English, Spanish, and Haitian Creole.

Indviduals interested in applying for the discount must provide proof of household income.

Acceptable forms of proof of household income (one of the following):

• W-2/income tax/1099
• Most recent 3 check stub
• Social Security letteror check stub
• Notarized letter from employer if self employed, paid in cash, etc
• Letter from unemployment office or unemployement check stub
• Notarized Self-Declaration of Income (to be used only if the applicant does not have a written income verifcation)(Refer to Self-Declaration Form)

** Eligibilty frot he SFDP is renewed annually with the receipt of updated documentation

A full discount is given to individuals and families with  annual incomes at or below 100% fo the FPG.  These patients will be charged a nominal fee (Slide A).  Sliding Scale fees are offered upt to 200% fo the FPG.  Borinquen Medical Centers cannot offer a discount to individuals and families with annual incomes above 200% of the FPG.

Waiver of Fees: Waiver of fees (non-collection of expected charges) are made availableto qualified patients.  Waiver of fees must be approved by the CFO/CEO.

WE WILL NOT DENY YOU SERVICE IF YOU DO NOT HAVE THE FINANCIAL ABILITY TO PAY OUR FULL FEES.

• Fee discounts are determined on the basis of your ability to pay.
• A full discount is given to you if your household’s annual income falls at or below 100% of the FederalPoverty Guidelines. You will be charged a nominal fee (our “A” rate).
• Sliding scale fees are offered up to 200% of the poverty guideline.
• We cannot offer a discount if your income is over 200% of the poverty guideline.

Schedule of Fee Discounts

* This Schedule is based on the most recent Federal Poverty Guidelines; updated annually.

We have a system in place to determine if you are eligible for discounted fees.

Fee discounts are determined on the basis of your ability to pay:

• A full discount is given to you if your household’s annual income falls below 100% of the Federal Poverty Guidelines. You will be charged a nominal fee (our “A” rate).
• Sliding scale fees are offered up to 200% of the poverty guideline.
• We cannot offer a discount if your income is over 200% of the poverty guideline.

WE WILL NOT DENY YOU SERVICE IF YOU DO NOT HAVE THE FINANCIAL ABILITY TO PAY OUR FULL FEES.

This Sliding Fee Schedule is based on the most recent Poverty Guidelines. It is updated annually.

Full list of fees are available upon request.

* May be bundled to contain multiple procedures