![NorthLakes Community Clinic [3]](https://nlcc3.l1.rm34.us/wp-content/uploads/2026/09/nlcc-logo-200x52.png){kind=logo}
How it Works
The Sliding Fee Scale uses federal rules to set your discounted rate based on federal income guidelines. You can apply whether you have insurance or not.
Your reduced rate works at all NorthLakes clinics for all services except court-ordered alcohol and other drug abuse assessments and medications when you already have prescription coverage. Download a Sliding Fee application or ask at your local NorthLakes clinic.
| Household Size | Annual Total Household Income |
|---|---|
| 1 | Up to $31,920 |
| 2 | Up to $43,280 |
| 3 | Up to $54,640 |
| 4 | Up to $66,000 |
| 5 | Up to $77,360 |
| 6 | Up to $88,720 |
For households with more than 8 people, add $11,360 per additional person at 200% of the federal poverty guideline.
Proof of Income
Income information is required for household members age 18 and older.
- Most recent federal 1040 tax return — preferred
- W-2s and 1099s, if applicable
- Pay stubs from the past three months
- Social Security, pension, annuity, or trust award letters
- Current unemployment statements or check stubs
- DHS Medical Enrollment forms
If these documents are not available:
- Payroll & Earnings Verification Statement (NL-Form 617)
- Last month’s bank statements showing income deposits (for Social Security only)
Complete the Self-Declaration of No Income form.
After You Apply
We will review your application and let you know whether you qualify. Please allow up to 30 days for processing.
Frequently Asked Questions
Call or visit any NorthLakes clinic to request an application, or view the application and instructions below.
For help, call 888.834.4551 and ask to speak with a Patient Financial Advocate.
Household members are people related by blood, marriage, or adoption who are legally and financially responsible for one another.
Yes. The sliding fee may help lower costs for services your insurance does not fully cover, including some dental care. You may also apply if you or your children have BadgerCare/Medicaid.
Your cost depends on your household income, household size, and the type of service you receive. Once approved, you’ll receive a letter explaining your cost responsibility. Payment is due at the time of service, or you can set up a payment plan.
Prescriptions written by NorthLakes providers may qualify for reduced-cost medication through a NorthLakes pharmacy.
Apply for the Sliding Fee
NorthLakes’ Sliding Fee may lower what you pay for care based on your household income and family size.
How to Apply
- Complete the application.
- Include proof of household income.
- Mail or drop off at any clinic.
Resources
Get Help
Our Patient Financial Advocates can answer questions or help you complete your application.
Call (888) 834-4551 and ask for a Patient Financial Advocate.