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  CURRENT FORMS 

• ​​BTAMC_Sliding Fee Scale Discount Program(SFS) Packet Form.docx - 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 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 Fee Schedule​
• ​Broad Top Area Medical Center Incident Report Form
  

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
  

FORMS & OTHER INFORMATION

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, 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 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 - $14,580            $14,581 - $18,225            $18,226 - $21,870            $21,871 - $25,515           $25,516 - $29,160            $29,161+

      2                   $0 - $19,720            $18,721 - $24,650            $24,651 - $29,580            $29,581 - $34,510           $34,511 - $39,440            $39,441+
      3                   $0 - $24,860            $24,861 - $31,075            $31,076 - $37,290            $37,291 - $43,505           $43,506 - $49,720            $49,721 + 
      4                   $0 - $30,000            $30,001 - $37,500            $37,501 - $45,000            $45,001 - $52,500           $52,501 - $60,000            $60,001 +        
      5                   $0 - $35,140            $35,141 - $43,925            $43,926 - $52,710            $52,711 - $62,495           $62,496 - $70,280            $70,281 + 
     6                   $0 - $40,280            $40,281 - $50,350            $40,351 - $60,420            $60,421 - $70,490           $70,491 - $80,560            $80,561 + 
      7                   $0 - $45,420            $45,421 - $56,775            $56,776 - $68,130            $68,131 - $79,485           $79,486 - $90,840            $90,841 +
      8                   $0 - $50,560            $50,561 - $63,200            $63,201 - $75,840            $75,841 - $88,480           $88,481 - $101,120          $101,121 + 

BTAMC will provide in-scope services to all patients, regardless of their ability to pay.   Every patient may apply for our Sliding Fee Scale Discount Program (SFS) to determine qualification. 

Eligibility for Sliding Fee Discounts  is based on the federal poverty level (FPL) income guidelines which are adjusted annually and operates 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 on-line or at our reception desk.

 Important discount program points are:

• The Sliding Fee Scale provides significant discounts for BTAMC Medical and Dental services
• The Sliding Fee Scale is not an insurance program- it is a benefit offered al ALL patients
  
• You must apply for the program to determine eligibility for Sliding Fee Scale Discounts
• ​You may qualify for the program, even if you have  medical insurance coverage
  
• You must provide documentation for proof of income to complete the application process
  
• Your eligibility is based on the gross income for your household and your household size
• You are encourage to re-apply anytime your household or household size changes, such as when someone becomes  unemployed,  or you add a family member, even then the 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 
• Applications & questions can be submitted to the office in person, by mail or via secure email to:​

                                                     enrollment@broadtopmedical.com

 2023 POVERTY GUIDELINES FOR THE 48 CONTIGUOUS STATES AND THE DISTRICT OF COLUMBIA
                              *For families/households with more than 8 persons, add $5,140 for each additional person.