Forms & Applications
Fee Schedule
A fee schedule is a complete listing of fees used by Medicare to pay doctors or other providers/suppliers. This comprehensive listing of fee maximums is used to reimburse a physician and/or other providers on a fee-for-service basis.
- These charges are rarely the price that patients pay. The Fee Schedule lists the dollar amount set for each service prior to insurance contract/benefit plan discounts or self-pay discounts being applied, so the price patients pay tends to be less than the standard charge.
- Hospital charges differ from patient to patient for the same service depending upon variations in treatment.
- Patients who are eligible for financial assistance also receive additional discounts.
Click on the link below to view the Fee Schedule:
Sliding Fee Discount Program
- Anyone can apply for the SFS, this discount is for people that are underinsured as well as uninsured.
- SFS eligibility is based on the Federal Poverty Guidelines put out by the U.S. Dept. of Health and Human Services’ Office of the Assistant Secretary for Planning and Evaluation.
- The SFS is offered a crossed all our Services (Medical, Behavioral Health, Dental)
Click on the link below to open the Sliding Fee Application:
2022 BFC Sliding Fee Discount Program Application
Discount Schedule:
| Poverty Level | Medical Rate/Medical Supply | Dental Rate/Dental Supply | Behavioral Health |
| 100% or Below | $20.00 Nominal Fee Rate/Cost | $40.00 Nominal Fee Rate/Cost | $0 Nominal Fee Rate |
| 101-150% | $40.00 Fee Rate per visit/Cost | $80 Fee Rate per visit/Cost | $5.00 Fee Rate per visit |
| 151-175% | $80.00 Fee Rate per visit/Cost | $120 Fee Rate per visit/Cost | $10.00 Fee Rate per visit |
| 176-200% | $120 Fee Rate per visit/Cost | $160 Fee Rate per visit/Cost | $15.00 Fee Rate per visit |
*Each Medical, Dental, or Behavioral Health visit, for each laboratory visit, and each medication is charged the fee that applies to the patient and is to be paid in full at the time of service.
*DISCOUNT LEVELS*: The total number of household members and their TOTAL income, earned and unearned, determines the discount level.
*Extra Supplies for Medical and Dental supplies are charged on an at cost. (Radiology, Prescriptions, Laboratory, Partials, Crowns, Dentures, or cosmetic appliances. Cost MUST be paid in full prior to supplies being provided given.
- Income Verification must be in the form of the latest tax return, Social Security/Disability, Self-employment net income, retirement, pensions, rental income, including Alaska Permanent Fund dividend or Tribal dividends, Child Support, Spousal Support, Foster Care, Workers’ Comp benefits and other Benefits including Disability, Veteran’s benefits. The last two paychecks stubs, paycheck stubs may be considered. This needs to be provided to BFC within 7 days from the date of application. o Once eligibility is approved, discounts are applied to the first visit and to subsequent visits.
- DEFINITION OF HOUSEHOLD MEMBERS: All individuals residing in the same home and sharing expenses are considered “household members”. Household members include: patient, spouse, significant other, grandparents, children, foster children, and other dependents.
- PATIENTS WITH INSURANCE: BFC will submit the full charge to the insurance company(ies) of patients who are also on the sliding fee program. Upon receipt of an EOB, the billing department shall apply the appropriate discount to the part that is the patient’s responsibility, unless the amount charges to the patient account is less than sliding scale rate. Then, the lower amount would be due.
• HARDSHIP WAIVER: A waiver of fees may be provided to a qualifying patient in an emergency situation and only if it would create a barrier to care. Any waivers must be approved by the CFO, COO or the Executive Director.
