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Caring For Our Community

Visit Forms & Sliding Scale Fee Application

Sliding Scale Discount Program

Kintegra will file all types of insurance for our patients.  We are dedicated to providing quality health care, health education and preventive care services to all members of the community regardless of financial barriers (ability to pay) through the regular publication of a sliding fee scale.   Kintegra offers  a discount program available for uninsured patients called a ‘sliding scale’ program.  This bases the patient’s fees on the amount of income in the household and the number of people living in the home.  Discounts described on the sliding scale reflect the eligible patient’s obligation based on family household income in relation to the Federal Poverty Guidelines, published annually.  Kintegra annually revises and re-issues the sliding scale to reflect changes in the Federal Poverty Guidelines.  Our sliding scale fee application forms are provided below. Our staff will assist you to determine your eligibility.  You can also fill out and bring the applicatoin with you to your visit.

Save time by completing these patient information packs before your visit with Kintegra!

For your Medical and/or Behavioral Health Visit

SPANISH

Adult Patient Information Pack (Spanish) 2020

Pediatric Patient Information Pack (Spanish)

Sliding Scale Fee Application (Spanish) 2020

 

ENGLISH

Adult Patient Information Pack (English) 2020

Pediatric Patient Information Pack (English) 2020

Sliding Scale Fee Application (English) 2020

Revocation of Consent to Release Patient Information 2020

For your Dental Visit:

Adult Patient Information Pack (English) 2020

Adult Patient Information Pack (Spanish) 2020

Pediatric Patient Information Pack (English) 2020

Pediatric Patient Information Pack (Spanish) 2020

Sliding Scale Fee Application (English) 2020

Sliding Scale Fee Application (Spanish) 2020

Photographing Your Teeth for your Teledentistry Visit