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Dental Clinic Eligibility Guidelines

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  • The patient must reside in Allen, Barren, Butler, Edmonson, Hart, Logan, Metcalfe, Monroe, Simpson or Warren counties. Patients are required to provide current Federal Tax 1040 information on first visit and then annually. Non-filing patients must complete a federal 4506-T (provided) to qualify for eligibility and charity care discounts.  

  • Patients with private pay dental insurance or whose annual family income falls above 250% of the national poverty guideline (NPG) are not eligible for services.

  • Patients are seen by appointment only. Failure to keep a scheduled appointment without 24-hour notification may dismiss the patient from future eligibility.

  • Patients are expected to pay the minimum service fee (as determined by a sliding scale) at the time of visit. The balance of the service fee may be billed, but payments are expected promptly to avoid bad debt and to avoid dismissal from future service.

 All qualifying patients will attest that their family income falls at or below 250% of the national poverty guidelines. See the table below for those guidelines.

Number of Persons in Family

$10

100% - 200%

$20

201% - 250%

1

$11,770 - $23,540

$23,541 - $29,425

2

$15,930 - $31,860

$31,861 - $39,825

3

$20,090 - $40,180

$40,181 - $50,225

4

$24,250 - $48,500

$48,501 - $60,625

5

$28,410 - $56,820

$56,821 - $71,025

6

$32,570 - $65,140

$65,141 - $81,425

7

$36,730 - $73,460

$73,461 - $91,825

8

$40,890 - $81,780

$81,781 - $102,225

For each additional add

$4,160

$10,400