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Family Size      Slide A(<=100%)    Slide B(101% - 125%)     Slide C(126% - 150%)     Slide D(151% - 175%)    Slide E(176% - 200%)     Above 200% FPL 

                             From - To                     From - To                            From - To                          From - To                         From - To
      1                   $0 - $13,590            $13,591 - $16,987            $16,988 - $20,385            $20,386 - $23,782           $23,783 - $27,180            $27,181+

      2                   $0 - $18,310            $18,311 - $22,887            $22,888 - $27,465            $27,466 - $32,042           $32,043 - $36,620            $36,621+
      3                   $0 - $23,030            $23,031 - $28,787            $28,788 - $34,545            $34,546 - $40,302           $40,303 - $46,060            $46,061 + 
      4                   $0 - $27,750            $27,751 - $34,687            $34,688 - $41,625            $41,626 - $48,562           $48,563 - $55,500            $55,501 +        
      5                   $0 - $32,470            $32,471 - $40,587            $40,588 - $48,705            $48,706 - $56,822           $56,823 - $64,940            $64,941 + 
     6                   $0 - $37,190            $37,191 - $46,487            $46,488 - $55,785            $55,786 - $65,082           $65,083 - $74,380            $74,381 + 
      7                   $0 - $41,910            $41,911 - $52,387            $52,388 - $62,865            $62,866 - $73,342           $73,343 - $83,820            $83,821 +
      8                   $0 - $46,630            $46,631 - $58,287            $58,288 - $69,945            $69,946 - $81,602           $81,603 - $93,260            $93,261 + 

FORMS & OTHER INFORMATION

  CURRENT FORMS ​

• BTAMC_SFS Application Form - we offer a sliding fee for payments for our services based on your income. Download this form to find out more. ​
• Broad Top Area Medical Center Patient Intake Form
  
• Broad Top Area Medical Center Registration(NEW) Medical Form 
  
• Broad Top Area Medical Center Registration(EST) Annual Form 
  
• ​Patient Bill of Rights and Responsibilities
  
• Notice of Privacy Practices
  
• Broad Top Area Medical Center Records Release Form
  
• ​Broad Top Area Medical Center Patient Grievance Form​
• Broad Top Area Medical Center Fee Schedule​

Family and Medical Leave Act (FMLA)

The Family and Medical Leave Act (FMLA) of 1993 is a United States labor law requiring covered employers to provide employees with job-protected, unpaid leave for qualified medical and family reasons.

• ​​FMLA_Notice of Eligibility Request
  
• ​FMLA_Notice of Designation-Determination
  
• ​FMLA_Cert of Provider for Employee
  
• FMLA_Cert of Provider for Family
  
• FMLA_Cert of Military Exigency
  
• FMLA_Cert of Provider for Military Employee
  
• FMLA_Cert of Provider for Military Family
  
• BTAMC_Employee FMLA Request Form 12.30.20
  
• ​​www.dol.gov
  

BROAD TOP AREA MEDICAL CENTER, INC

FEDERAL POVERTY GUIDELINES – SLIDING FEE SCALE PATIENT EDUCATION

Broad Top Area Medical Center Inc., (BTAMC) is a non-profit Federally Qualified Health Center whose mission is to provide access to affordable, high-quality healthcare without discrimination based on race, color, sex, disability, age, creed, or national origin.

 

BTAMC will provide in-scope services to all patients, regardless of their ability to pay.  The Sliding Fee Discount program is offered to under-insured and uninsured patients based on their household size and family income.  All patients are encouraged to apply.  The Sliding Fee Discount schedule is based on the federal poverty level (FPL) income guidelines which are adjusted annually and operates in accordance with other federal program regulations.  An application for the Sliding Fee Discount program is available at our reception desk.

 Important discount program points are:

• The Sliding Fee Scale is not an insurance program
• The Sliding Fee Scale provides significant discounts for BTAMC services
• You must apply for the Sliding Fee Scale Benefits
• You must provide information for proof of income. Your eligibility is based on your household size and the gross income for your household.
• You may qualify for the program even if you have medical insurance coverage
• You are encourage to re-apply anytime your household size or income changes, such as someone becoming unemployed or adding a family member, even when a change is temporary
• You must renew applications and submit proof of income, annually
• The Sliding Fee Scale benefit year is from March 1st through Feb. 28th or 29th 

 2022 POVERTY GUIDELINES FOR THE 48 CONTIGUOUS STATES AND THE DISTRICT OF COLUMBIA
*For families/households with more than 8 persons, add $4,720 for each additional person.