Sliding Fee Application

Thank you for your interest in the Sliding Fee Application. If you are applying for a sliding fee discount of indigent medications, please furnish proof of income by supplying a copy of last year’s tax return. You will have 7 business days to supply proof of income.  If not provided within this time, full charges will apply. Without proof of income, your application will not be processed and your enrollment into the program will be delayed.

Additionally, If there are special issues you feel should be considered when we review your application, please include those in the designated area of this application.

If you do not have any income to report, please complete the Zero Income section below. All income changes must be reported to the clinic. This application is good for 1 year before you will be asked to reapply.

Please fill out this online form below and then drop off a copy of last year’s tax return at our clinic, located at 8591 Holly Meadows Road, Parsons, WV 26287.

    Applicant Information

    Household Information


    Zero Income Information

    Disclaimer and Signature

    By signing the application, I understand that my copay is due at the time of each visit. I also understand that if I knowingly provide false information, any sliding fee discount received will be removed and I will be barred from receiving future discounts.

    Our Main Clinic

    8591 Holly Meadows Road
    Parsons, WV 26287

    Phone: 304-478-3339
    Fax: 304-478-3311

    Patient Portal

    Manage your medical information online. Click here