Charlotte Community Health Clinic, Inc.
ESTABLISHED PATIENT SLIDING FEE DISCOUNT PROGRAM APPLICATION
Charlotte Community Health Clinic is committed to providing quality health care to all members of the
community regardless of their ability to pay.
All patients of Charlotte Community Health Clinic with household income at or below 200% of the Federal
Poverty level and that provide required documentation will be eligible for medical, dental, and prescription
Two pieces of information are required in order to qualify: the amount of money earned in the household and
the number of people who live in the household. To be eligible for the Sliding Fee Scale, you must provide
accurate and acceptable proof of income as well as list all persons within the household.
PLEASE RETURN THE ATTACHED APPLICATION AND PROOF OF INCOME (see below list) TO CCHC PRIOR TO YOUR
NEXT APPOINTMENT OR YOU WILL BE RESPONSIBLE FOR 100% OF ALL CHARGES AT THAT APPOINTMENT.
PLEASE PROVIDE COPIES – WILL NOT BE RETURNED
(Documents will be shredded for privacy after use)
Acceptable Proof of Income – Provide for each adult listed on application
• Most recent Federal Income Tax Return
• W-2 forms
• 30 days most recent pay stubs (more is better)
• Employer’s Letter on letterhead (must include contact name and phone number)
• Agency letter: A letter from the Social Security Administration, Veterans Administration or Social
Service Agency indicating income level.
• Unemployment Verification: Paperwork from the Employment Securities Commission (ESC)
proving unemployment status and the amount of unemployment compensation being
• Alimony or Child Support Agreement
• Bank statement (only if it shows a direct deposit)
• Official Paperwork: Paperwork documenting retirement, disability, SSI benefits.
• If homeless: Letter from shelter where you are getting services
• If homeless/doubling up: Doubling up verification form
• If completely supported by a friend/relative, signed letter of support from that person
Complete and sign the attached application and return to CCHC, along with proof of income prior to
your next appointment:
Via email to email@example.com
In person to Charlotte Community Health Clinic, 8401 Medical Plaza Dr, Suite 300, Charlotte, NC 28262
In person to Charlotte Community Health Clinic, 5301 Wilkinson Blvd, Charlotte, NC 28208