Insurance and payments for services

These outreach and enrollment services are FREE to you and your family.

In order for our coordinators to assist you in applying for coverage, you must meet certain citizenship requirements (some non-citizens may apply), be an Ohio resident, have a social security number and meet certain financial requirements.

Documentation needed

Birth certificate
Social security card
Verification of address & citizenship
Valid driver’s license or passport
Verification of income and resources

How to Qualify for a Sliding Fee Scale

Total household income must not exceed 200% of the Federal Poverty Guidelines
Proof of household income is required, such as income tax return, copies of your last pay stubs, W-2 or proof of government assistance. Program details and an application can be obtained by clicking on the forms below or from the registration staff.

Sliding Fee Scale Application Form

Individuals without insurance are welcome to become patients at Five Rivers Health Centers, as we accept patients regardless of their ability to pay. Discounts are offered to members of households with combined income of 200% and below of the Federal Poverty Level. To determine if you qualify, complete the form (either online or print) prior to your first appointment. Our Outreach & Enrollment Specialists will be happy to assist you with this process.

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