Step 1: Tell our front desk receptionist that you would like to apply or download a copy of the application by clicking  

Step 3: Complete the application and return it to a patient account representative at The Purcell Clinic. 

Step 4: Provide proof of income with one of the following accepted means of documentation:

  • Prior Year W-2
  • Two Most Recent Pay Stubs
  • Letter From Employer
  • Form 4506-T (if W-2 not filed)
  • Self-Employed Income/Expense information for last 3 months
  • Self-Declaration of Income (for those who have no income)

Step 5: Our Patient Account Representative will apply your income information to the sliding fee discount chart and inform you of your eligibility.

 Discounts range from 0-100% and are based on income and family size only.

The Purcell Clinic encourages all who are unable to pay for their services to apply for this program. Eligibility is based solely on an individual’s income and family size. Any individual with income at or below 200% of the Federal Poverty Guidelines is eligible for this program. Your income and family size will be applied to the chart below and you will receive the corresponding discount on all past balances as well as all services going forward for a period of one year unless your income or family size changes. After one year or in the event of those changes, you may reapply for the program.

This image uses a $100 balance to reflect examples of applicable discounts depending on family size & income. 


The Purcell Clinic offers this program in an effort to remove barriers to affordable care for uninsured or underinsured individuals with income at or below 200% of the Federal Poverty Guidelines. The Purcell Clinic will offer a Sliding Fee Discount Program to all who are unable to pay for their services. The Purcell Clinic will base program eligibility on a person’s ability to pay and will not discriminate on the basis of age, gender, race, sexual orientation, creed, religion, disability, or national origin. The Federal Poverty Guidelines, are used in creating and annually updating the sliding fee schedule (SFS) to determine eligibility.