Patient Information

La Esperanza Clinic offers several payment methods which allow patients to have access to the care they need at a cost they can afford.

  • Sliding Fee Scale Discount Program

  • Medicare/Medicaid
     

  • Private Insurance

  • VISA/Master Card, Cash & Check
     

  • On-site assistance with applying for state services such as Medicaid and CHIP​

Proof of income is required from all members in the patient's household in order for a patient to be eligible for the Sliding Fee Scale Discount Program 

Proof of Earned Income:

If patient gets paid, bring most recent pay stubs

  • One month of most recent pay stubs
     

  • if no pay stubs, provide Employment Verification Form

If patient does not have stubs or copies of checks, the patient can have their employer fill out an Employment Verification Form. For all patients, a filed tax return will be accepted until June 30 of the current year.

Proof of Unearned Income:

  • Current year Social Security Award Letter for Supplemental Income
     

  • Unemployment Benefits for current year Disability Award Letter
     

  • Pell Grants
     

  • Child Support (current printout from the Attorney General's office)
     

  • Retirement check for current year or statement showing payments

No Income:

  • Bring a letter of support (w/ the $ amount provided in a month) and a copy of the picture ID of the supporter if they will not be present at the appointment
     

  • Patients staying at a shelter should provide a letter of Support on a Business Letterhead

 

Note: ​If visit is not covered or paid in full, any remaining balances will be billed to patient.

Good Faith Estimate

Under federal law, health care providers must give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

You have the right to receive a “Good Faith Estimate” for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

You can use the tools above or contact us for a Good Faith Estimate before you schedule an item or service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit https://www.cms.gov/nosurprises or call 214-633-4036.