Our website is currently going through maintenance and will be updating soon.

CURRENT FORMS:

• Broad Top Area Medical Center Sliding Fee Scale Discount Program (SFS) Packet 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 Fee Schedule​
• Broad Top Area Medical Center Registration (NEW) Patient Packet​
• Broad Top Area Medical Center Registration (EST) Annual Patient Packet
  
• Patient Bill of Rights and Responsibilities​​
• Notice of Privacy Practices 
  
• Broad Top Area Medical Center Records Authorization Form 
  
• Broad Top Area Medical Center Patient Grievance Form
  
• Broad Top Area Medical Center Incident Report Form

BROAD TOP AREA MEDICAL CENTER, INC

2025 SLIDING FEE SCALE DISCOUNT PROGRAM-PATIENT EDUCATION & INTEREST FORM

FEDERAL POVERTY GUIDELINES 

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

 

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
  

BTAMC will provide in-scope services to all patients, regardless of their insurance status or ability to pay. Every patient may apply for our Sliding Fee Scale Discount Program (SFS) to determine qualification. Patients may choose to decline the benefit program.

Eligibility for Sliding Fee Discounts  is based on the federal poverty level (FPL) income guidelines which are adjusted annually and operate in accordance with other federal program regulations.  ALL patients are encouraged to apply.  Uninsured and under-insured patients may qualify for the program based on their household size and their family's income. Sliding Fee Scale Discount Program applications are available at every BTAMC reception desk and on-line - visit  www.broadtopmedical.com

 Important discount program points are:

• The Sliding Fee Scale provides significant discounts for BTAMC Medical and Dental services at every BTAMC locations
• The Sliding Fee Scale is not an insurance program- it is a benefit offered al ALL patients
  
• The Sliding Fee Scale benefit year is from March 1st to the last day of February
  
• Your eligibility is based only on your household size and the gross income for your household
  
• ​You may qualify for the program, even if you have third-party medical insurance and/or dental coverage
  
• You will qualify for the program if your household income is below and/or up to 200% of the federal poverty level
  
• You must apply for the program to determine eligibility for Sliding Fee Scale Discounts​
• You must provide proof of income along with your application such as tax forms or pay stubs or bank statements
• You are encourage to re-apply anytime your household income or household size changes, such as when someone loses insurance, someone becomes  unemployed,  or if you add or  lose a family member - even when the change is temporary
• You must renew application and submit proof of income each year to qualify for Sliding Fee Scale Discounts
• Applications & questions can be submitted to the office in person, by mail or via secure Email to:​

                                                               enrollment@broadtopmedical.com

 2025 POVERTY GUIDELINES FOR THE 48 CONTIGUOUS STATES AND THE DISTRICT OF COLUMBIA
  *For families/households with more than 8 persons, add $5,500 for each additional person. 

• 2024 Sliding Fee Scale Discount Program-Patient Education & Interest Form
  

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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 - $15,650            $15,651 - $19,563            $19,654 - $23,475            $23,476 - $27,388           $27,389 - $31,300            $31,301+

      2                   $0 - $21,150            $21,151 - $26,438            $26,439 - $31,725            $31,726 - $37,013           $37,014 - $42,300            $42,301+
      3                   $0 - $26,650            $26,651 - $33,313            $33,314 - $39,975            $39,976 - $46,638           $46,639 - $53,300            $53,301+ 
      4                   $0 - $32,150            $32,151 - $40,188            $40,189 - $48,225            $48,226 - $56,263           $56,264 - $64,300            $64,301+        
      5                   $0 - $37,650            $37,651 - $47,063            $47,064 - $56,475            $56,476 - $65,888           $65,889 - $75,300            $75,301+ 
     6                   $0 - $43,150            $43,151 - $53,938            $53,939 - $64,725            $64,726 - $75,513           $75,514 - $86,300            $86,301+ 
      7                   $0 - $48,650            $48,651 - $60,813            $60,814 - $72,975            $72,976 - $85,138           $85,139 - $97,300            $97,301+
      8                   $0 - $54,150            $54,151 - $67,688            $67,689 - $81,225            $81,226 - $94,763           $94,764 - $108,300          $108,301+ 

FORMS & OTHER INFORMATION