Sliding Fee Scale

We want you to get the care you need, even if you do not have insurance and cannot pay full price. Our sliding fee scale may remove or lower your cost. This discount program is a federal program that allows NorthLakes to discount our charges for health card services.

How a Sliding Fee Scale Works

The amount you pay depends on how much money your family makes and how many people live with you. We use federal rules to set your discounted rate. Your reduced rate works at all NorthLakes clinics for all services except court-ordered alcohol and other drug abuse assessments and medications (if you already have prescription coverage).

Ask for a sliding fee scale packet at the front desk of any clinic or during your appointment.

Income from ALL household members over the age of 18 must be submitted. Applications may be denied if not received by the return date on the application.

Accepted documents for proof of income:

  • Most current 1040 tax form (preferred)
  • W2s (include 1099 tax form if applicable)
  • 3 months of most recent pay stubs
  • Award letters from Social Security or pensions, annuities, trust funds
  • Most current unemployment statements or check stubs
  • DHS Medicaid Enrollment forms

If you cannot provide any of the above, please include:

  • Payroll & Earnings Verification Statement (NL-Form 617)
  • For Social Security only: Last month’s bank statements showing income deposits

If you have no income:

Complete the application and include your proofs of income, and mail or drop off at any of our NorthLakes locations.

Within 30 days, you will receive notice of your sliding fee eligibility.

2026 Income Guidelines

Household Size Annual Gross Household Income
  1 Up to $31,920
  2 Up to $43,280
  3 Up to $54,640
  4 Up to $66,000
  5 Up to $77,360
  6 Up to $88,720

For each additional person, add $11,360/year for families over 200% of poverty.

Do you qualify?

Call or visit any of our clinics to request an application or view the application and instructions in the list below. If you need assistance, call 888.834.4551 and ask to speak with a Patient Financial Advocate.

Who is considered a household member?

Household members are related by blood, marriage, or adoption, and are legally and financially responsible to each other.

What if you have insurance?

The sliding fee scale may help you pay less for things your insurance does not cover—like extra dental work. You can apply even if you or your children have BadgerCare/Medicaid.

How much will I pay with the Sliding Fee Scale?

The charge for your visit depends on income, household size, and the type of service you received. Once approved, you will receive a letter that details your cost respionsibilities. Payments are due at time of service, or set up a payment plan.

Are medications covered?

Prescriptions written by our providers may be able to receive a subsidy for prescription drugs through a NorthLakes pharmacy.

Contact Us

Patient Financial Advocates are available to answer questions for help with filling out the Sliding Fee Scale application.

(888) 834-4551

Understanding Our Sliding Fee Scale