Effective Date: September 1, 2026
Policy: To make available free or discounted services to those in need.
PURPOSE
All patients seeking health care services at MILES FOR SMILES MOBILE DENTAL CARE are assured that they will be served regardless of ability to pay. No one is refused service because of lack of financial means to pay. This program is designed to provide free or discounted care to those who have no means, or limited means, to pay for their medical services (uninsured or underinsured).
MILES FOR SMILES MOBILE DENTAL CARE will offer a Sliding Fee Discount Program to all who are unable to pay for their services. MILES FOR SMILES MOBILE DENTAL CARE will base program eligibility on a person's ability to pay and will not discriminate on the basis of an individual's race, color, sex, national origin, disability, religion, age, sexual orientation, or gender identity. The Federal Poverty Guidelines are used in creating and annually updating the sliding fee schedule (SFS) to determine eligibility.
PROCEDURES/GUIDELINES
Families up to and including 100% FPL will be expected to pay a nominal fee of $10
Families up to and including 150% FPL will be expected to pay a nominal fee of $20
Families up to and including 200% FPL will be expected to pay a nominal fee of $25
Emergent Care only; The sliding fee scale schedule is offered to patients in pain and need immediate access to care based upon their income. (1 tooth completion per date of service)
Each Visit for further services will be subject to the nominal fee based on income.
Once initial services for emergent visits are completed; patients will no longer be considered for the sliding fee scale and will be placed on Miles for Smiles regular cash discount program.
Sliding fee scale patients will not be sent to collections based upon inability to pay.
MILES FOR SMILES MOBILE DENTAL CARE places notification of Sliding Fee Discount Program in the clinic waiting area.
An explanation of our Sliding Fee Discount Program and our application form are available on MILES FOR SMILES MOBILE DENTAL CARE's website.
Request for discount: Requests for discounted services may be made by patients, family members, social services staff or others who are aware of existing financial hardship. The Sliding Fee Discount Program will only be made available for clinic visits. Information and forms can be obtained from the Front Desk and the Business Office.
Administration: The Sliding Fee Discount program procedure will be administered through the Business Office Manager or his/her designee. Information about the Sliding Fee Discount Program policy and procedure will be provided to patients. Staff are to offer assistance for completion of the application. Dignity and confidentiality will be respected for all who seek and/or are provided health care services.
Completion of Application: The patient/responsible party must complete the Sliding Fee Discount Program application in its entirety. Staff will be available, as needed, to assist patient/responsible party with applications. By signing the Sliding Fee Discount Program application, persons are confirming their income to MILES FOR SMILES MOBILE DENTAL CARE as disclosed on the application form.
Eligibility: Discounts will be based on income and family size only.
a. Family is defined as: a group of two people or more (one of whom is the householder) related by birth, marriage, or adoption and residing together; all such people (including related subfamily members) are considered as members of one family. MILES FOR SMILES MOBILE DENTAL CARE will also accept non-related household members when calculating family size.
b. Income includes: gross wages; salaries; tips; income from business and self-employment; unemployment compensation; workers' compensation; Social Security; Supplemental Security Income; veterans' payments; survivor benefits; pension or retirement income; interest; dividends; royalties; income from rental properties, estates, and trusts; alimony; child support; assistance from outside the household; and other miscellaneous sources.
Income verification: Applicants may provide one of the following: prior year W-2, two most recent pay stubs, letter from employer, or Form 4506-T (if W-2 not filed). Self-employed individuals will be required to submit detail of the most recent three months of income and expenses for the business. Adequate information must be made available to determine eligibility for the program. Self-declaration of Income may be used. Patients who are unable to provide written verification may provide a signed statement of income.
Waiving of Charges: In certain situations, patients may not be able to pay the nominal or discount fee. Waiving of charges must be approved by MILES FOR SMILES MOBILE DENTAL CARE's designated official. Any waiving of charges should be documented in the patient's file along with an explanation.
Applicant notification: The Sliding Fee Discount Program determination will be provided to the applicant(s) in writing and will include the percentage of Sliding Fee Discount program write off, or, if applicable, the reason for denial.
Record keeping: Information related to Sliding Fee Discount Program decisions will be maintained and preserved in a centralized confidential file located in the Business Office Manager's Office, in an effort to preserve the dignity of those receiving free or discounted care.
a. Applicants that have been approved for the Sliding Fee Discount Program will be logged in MILES FOR SMILES MOBILE DENTAL CARE's practice management system, noting names of applicants, dates of coverage and percentage of coverage.
Policy and procedure review: The SFS will be updated based on the current Federal Poverty Guidelines. MILES FOR SMILES MOBILE DENTAL CARE will also review possible changes in our policy and procedures and for examining institutional practices which may serve as barriers preventing eligible patients from having access to our community care provisions.
Budget: During the annual budget process, an estimated amount of Sliding Fee Discount Program service will be placed into the budget as a deduction from revenue.
Please contact our team at 318-317-2800 if you have any questions or to schedule your appointment with our general dentists in Shreveport and Baton Rouge, LA.