Answer a few quick questions to find out if you may qualify for our Sliding Fee Discount Program.
About youStep 1 of 5
Let's start with who you live with.
Do you live with a spouse or an unmarried partner?
Add each child under age 19 who lives with you.
Important:Only count children under 19 who live with you. Children living somewhere else are not counted, even if you send money to support them.
Do you have any children under 19 living with you?
Add a child under 19
Almost there! One more quick question.
Just so you know:These adults are NOT counted in your household. We ask only because it helps us give you the most accurate answer.
Are there other adults age 19 or older living in your home (besides you and your spouse/partner)?
For example: parents, adult children (age 19+), brothers or sisters, roommates, or other relatives.
For each adult in your household, tell us about your income. If you have more than one source (like a job plus DoorDash), add each one.
Documents to bring or send
Below is the list of documents we need. Two full months of documents are required.
Please do NOT send:
Paychecks (we need pay stubs, which show details)
Bank statements
Screenshots without dates
Partial or missing months
If you cannot get the documents listed above, please call us before your appointment and we'll discuss other options.
Send your documents now
When you have your documents ready, click the button below. It will open your email program with a message already started — just attach your documents and send.
Or send to:medical@upfh.org
Call us to schedule your appointment
Our team will walk you through everything you need.
Answer any questions about the program or your visit cost
Your privacy:This tool does not save any information you enter. Once you close this page, all of your answers are gone. This is an estimate only — your final discount will be confirmed when you bring your income documents to your appointment.