treated here. Proof of income can be
shown using:
- Check stubs from work
- Copy of last year’s tax form
- Copy of your vision card
- Copy of benefits received (Social
Security, unemployment benefits, etc.)
If you are unsure that your proof of
income will qualify you for services, please give us a call at
785-312-7770 to discuss your situation.
If you are relying on a third party to
pay for these services, they must meet the federal poverty guidelines
and they must provide proof of income from the list above.
Individuals over the age of 15 must
first see the dentist for an examination and X-rays before any other
appointments for non-emergency cleanings, fillings, etc. can be set.
We require that you fill out our paperwork
and bring it in, along with a photo ID and proof of income and/or
medical card, before we can set an appointment. Click
HERE to view and print out
our new patient paperwork. Bring the
filled out forms to the clinic and we'll be more than happy to setup an
appointment if you qualify to be seen here. The document is
formatted in Adobe Acrobat format. If you don't have Adobe Acrobat
Reader on your computer, please click
HERE. In order to be seen here, you must meet
our income guidelines. Starting in 2010, we are able to see
patients that are at 250% of 2008 federal poverty guidelines as
determined by the State of Kansas' SCHIP guidelines. Our income
guidelines are as follows:
|
# of people in household |
Fee Level 1 |
Fee Level 2 |
Fee Level 3 |
Fee Level 4 |
|
1 |
$10,830/year or $903/month |
$16,244/year or $1,353/month |
$21,659/year or $1,804/month |
$26,000/year or $2,167/month |
|
2 |
$14,570/year or $1,214/month |
$21,854/year or $1,820/month |
$29,139/year or $2,427/month |
$35,000/year or $2,917/month |
|
3 |
$18,310/year or $1,526/month |
$27,464/year or $2,288/month |
$36,619/year or $3,051/month |
$44,000/year or $3,667/month |
|
4 |
$22,050/year or $1,838/month |
$33,074/year or $2,755/month |
$44,099/year or $3,674/month |
$53,000/year or $4,417/month |
|
5 |
$25,790/year or $2,149/month |
$38,684/year or $3,223/month |
$51,579/year or $4,297/month |
$62,000/year or $5,167/month |
|
6 |
$29,530/year or $2,461/month |
$44,294/year or $3,690/month |
$59,059/year or $4,921/month |
$71,000/year or $5,917/month |
|
7 |
$33,270/year or $2,773/month |
$49,904/year or $4,158/month |
$66,539/year or $5,544/month |
$80,000/year or $6,667/month |
|
8 |
$37,010/year or $3,084/month |
$55,514/year or $4,625/month |
$74,019/year or $6,167/month |
$89,000/year or $7,417/month |
For family units with more
than 8 members, add $3,740, $5,610, $7,480, or $9,000 for each additional member. |