www.sawtoothmountainclinic.org
513 5th Ave. W., Grand Marais, MN 55604, Phone: 218-387-2330 Fax: 218-387-1278
Sandy L Stover, MD; Paul E Terrill, MD; Jennifer L Delfs, MD; Michael R Sampson, MD; Milan C Schmidt, MD;
Kurt Farchmin, MD; Lisa M Zallar, CNP
Service Mission of Sawtooth Mountain Clinic: To provide access to high quality, comprehensive,
primary healthcare in Cook County to all users, regardless of financial ability to pay for services.
Sliding Fee Scale Application
The sliding fee scale program is income based – offered by the U.S. Department of Health & Human
Services, :330 federal grant funding – available to all – regardless of existing insurance coverage.
Your provider may not know program details. Please contact Steve Fleace, 387-2330, Ext. 113.
steve@sawtoothmountainclinic.org; or Erin Watson, ext. 153, erin@sawtoothmountainclinic.org.
A. Sliding Fee Scale Program.
1. This program is available to patients of the Sawtooth Mountain Clinic, and is dependent on the
annual renewal of the federal grant.
2. This program covers medical outpatient services received at the Sawtooth Mountain Clinic and
the lab, physical therapy, and x-ray departments of the Cook County North Shore Hospital. It
does not cover charges if you are hospitalized or are seen in the hospital’s emergency room.
3. The patient will pay a small fee of $5.00 or $10.00 per visit or prescription.
4. All patients must reapply for the program yearly. Eligibility for the previous year ends on
May 1 and a new application must be filed if the patient wishes to continue participation.
B. Eligibility: Income must be within federal guidelines for family size (see attached chart). You
may have other insurance and still be eligible.
C.
1.
2.
3.
Instructions for Application:
Obtain application form from receptionist at the clinic.
Read sliding scale program description and complete the application form.
Attach proof of income to application. Examples of proof of income: Photocopy of W-2 form,
front two pages of federal income tax return, social security check, pay stubs, or unemployment
letter.
Program Benefits
1. Clinic Services:
Coverage: Most medical services obtained at the Sawtooth Mountain Clinic are covered. SMC
reserves all rights to review what will be eligible for sliding scale discount.
Billing: The Sawtooth Mountain Clinic will submit a claim to any insurance company for which you
provide membership information. After insurance has processed, the remainder of the charges are
adjusted. You will be billed only for the percentage you owe.
2. Other Services:
Special order needs, certain travel immunizations, or birth control devices will be reviewed on an
individual basis.
3. Hospital Services:
Patient must notify the North Shore Hospital that he/she is a participant in the sliding scale
program.
 Coverage: The sliding fee scale will only cover charges from North Shore Hospital if they were
ordered by Sawtooth Mountain Clinic providers.
 The following services, if ordered by Sawtooth Mountain Clinic, will be covered:
a. Outpatient laboratory tests,
b. Outpatient x-ray and diagnostic tests,
c. Outpatient physical and occupational therapy with services of $1000 maximum per calendar
year. Does not cover post op physical therapy or post specialist consultation physical therapy orders.
For questions about physical therapy coverage, call Steve Fleace, 387-2330 ext. 113; or Erin Watson,
387-2330 ext. 153
 Our program does not cover cardiac rehab, supplies, IV therapy, in-patient/observation at the
hospital, Care Center charges or prescriptions while in the Care Center.
 Billing: The hospital will submit a claim to your insurance company. You are responsible to let
the hospital know you are on sliding scale. The hospital will then bill the clinic directly for your
charges. The clinic will adjust the bill and send you a statement for the percentage you owe.
4. Medicine and Drugs:
 Coverage: Only prescriptions written by a Sawtooth Mountain Clinic Provider and obtained at
the Arrowhead Pharmacy or Grand Marais Pharmacy in Grand Marais will be covered. (**Patient
shall pay 5% at Level A, 25% at Level B, 50% at Level C, and 75% at Level D, for pharmacy
coverage.)
 Prescriptions are not covered if they are written for items available over-the-counter, with the
exception of diabetic supplies – these are covered with a written prescription (yearly) from one of
Sawtooth Mountain Clinic’s providers. Prescriptions written for use as an in-patient at the North
Shore Hospital or Care Center will not be covered.
5. Dental Care for patients of SMC:
Coverage: The sliding scale will cover up to $1,000 annually per patient for services provided by
Drs. Hedstrom and Lindquist’s office, Grand Marais Family Dentistry. The dentist can request
additional coverage from the clinic for special situations that are medically necessary.
Dental Insurance: If you have dental insurance, the dentist office will submit a claim to your
insurance carrier and then bill the clinic directly for the remaining charges. The clinic will send you a
statement for the percentage you are responsible for.
6. Counseling and Support Referrals for patients of SMC:
Sliding scale will provide up to 15 visits per year with counseling and support providers in our
community. Currently participating are Linda Vanden Brook, MA, LMFT, at 4 Directions; Wayne
Arnzen, MA, LP; Kelly Senty, M.A., at Steps of Change; Sherri Moe, MS; and the Human
Development Center. Please tell your counseling provider that you are on Sawtooth Mountain
Clinic’s sliding scale program at time of registration or at your appointment.
Billing: Your counseling provider may bill you. If you receive a bill, bring it to Steve Fleace at the
Sawtooth Mountain Clinic.
7. Vision Care for patients of SMC:
The sliding scale will cover basic vision exams up to twice per year as necessary. Exams must be
performed by St Luke’s Ophthalmology Associates located at the Cook County North Shore Hospital
and Care Center. Sliding scale will not cover glasses or contacts.
St Luke’s will submit a claim to your insurance company. You are responsible to let St Luke’s know
that you are on sliding scale. St Luke’s will then bill the clinic directly for your charges. The clinic
will adjust the bill and send you a statement for the percentage you owe.
8. Referrals:
Consultations:
 The sliding scale will cover an initial outpatient consultation, when the referral is made by a
Sawtooth Mountain Clinic Provider.
 Billing: Please notify your specialist’s office, at the time you register, that you wish to have them
file your insurance claim for you. The specialist will bill you. You must then bring your bill to the
Sawtooth Mountain Clinic. We will adjust consultation fees based on sliding scale eligibility.
 The specific services authorized are covered by the sliding scale, but if you seek continued care at
the specialist, it will not be covered, even if for the condition originally treated.
 If the specialist hospitalizes you, please remember that the sliding fee scale covers no
inpatient costs.
Chiropractic Care for patients of SMC, with referral:
 Sawtooth Mountain Clinic Providers may refer you for complimentary medical services available
in Cook County. The sliding fee scale program will cover services up to $500.00/calendar year.
A referral slip from a Sawtooth Mountain Clinic Provider must be given to the Chiropractor
(Malin Aseby-Gesch, D.C. or Loren Stoner, D.C.) to be eligible for this benefit. SMC does not
cover x-rays ordered by the Chiropractor.
Hearing Aid Assistance for SMC patients, with referral:
Sawtooth Mountain Clinic Providers may refer you for assistance of up to $1,000.00/calendar year for
the purchase of hearing aids when arranged through hearing providers visiting SMC. Hearing
assistance will be reviewed on a case by case basis and must be pre-approved.
Physical Therapy for SMC patients, with referral:
In addition to physical therapy through the Cook County North Shore Hospital referenced above,
Sawtooth Mountain Clinic Providers may refer you for physical therapy services to Becky Stoner P.T.
at the Grand Marais Wellness Center. The sliding fee scale program will cover up to
$1,000.00/calendar year. A referral slip from a SMC Provider must be given to the physical therapist
to be eligible for this benefit. SMC does not cover x-rays ordered by the physical therapist.
Acupuncture, Acupressure, Homeopathic, Healing Touch, Massage and Art Therapy for SMC
patients, with referral:
Sawtooth Mountain Clinic Providers may refer you for services up to $500.00/calendar year per
provider type. A referral slip from a Sawtooth Mountain Clinic Provider must be given to the
provider to be eligible for these benefits. Eligible providers include Mona Abdel-Rahman L.Ac. at
Crescent Moon Acupuncture LLC; Jessi Nicholson L.Ac.M.O.M. at Quiet Waters Acupuncture and
Herbal Medicine; Debi LaMusga H.T.P. at Anahata Healing Touch; Christal Stone Kelahan MT at
Therapy by the Lake; Laurie J. Senty BCTMB at Shiatsu Therapy and Therapeutic Massage; Trish
Francis C.M.T. at Well Springs Therapy; Carol Einwalter NBCMT LMT and staff at WatersMeet
Wellness Center; Margy Nelson C.M.T. Homeopath; Natalie Sobanja MT; Suzabelle Janicek ATR
MFA MA; and Pamela Faye, RN, CHTP, Healing Touch and Massage Therapy.
9. Lab & x-ray:
Lab charges from Medtox will be covered for pathology. X-ray charges from Consulting Radiologists
will be covered for x-ray interpretations. MRI mobile unit (available at North Shore Hospital) x-ray
charges will be covered one time/calendar year. The Providers at Sawtooth Mountain Clinic must
authorize these outpatient services. If you receive a bill, please bring it to Steve Fleace or Erin
Watson at the SMC.
10. Other Area Services:
 Cook County North Shore Hospital has a Community Care program available for qualified
patients. Call 387-3040 for more information.
 Oral Health Task Force has a sliding fee program for children’s additional dental care. Call the
Grand Marais Family Dentistry at 387-2774 to inquire about this program.
Please keep these instructions for future use.
Slide/2015 appl 10/2015
This program is made available through the U.S. Department of Health and Human Services, Community
Health Centers, section :330 grant funding. Sawtooth Mountain Clinic is a 501©(3) not-for-profit organization.
Sawtooth Mountain Clinic, Inc.
Sliding Scale Statement of Financial Position
OFFICE
USE
_______%
_______
___________________
_______
Applicant’s Name______________________________
Date of Birth
Spouse’s Name ________________________________
Date of Birth ___________________
Mailing Address__________________________________________________________________
Home Telephone_______________________________
Work Telephone (Spouse)_______________________
Work Telephone__________________
Family Dependents (living at home):
First Name
Birth Date
Last Name if Different
________________________
________________________
________________________
__________________
(Attach separate sheet if more space is needed.)
Insurance Co. Name
Do you plan to apply for Medical Assistance? ________
Social Security Number _____________________
Group #.
Policy # _________________
Earned Income $___________________ /year. Social Security/Pensions $________________
Unemployment Income $_____________Self employed adjusted gross income $___________
Interest Income $____________________
TOTAL: $______________________________
Type of Income verification: _________________
PLEASE CHECK OR CIRCLE ONE THAT APPLIES:
RACE:
 Hispanic or Latino  Asian  Caucasian
American Indian or Alaskan Native Black or African American
Native Hawaiian
Pacific Islander
ETHNICITY: Hispanic or Non-Hispanic
VETERAN:
 More than one race
Yes 
No 
I hereby acknowledge that I have read these instructions.
Sawtooth Mountain Clinic and Cook County North Shore Hospital may share my income information to determine
program availability. I understand that the Sawtooth Mountain Clinic’s sliding scale of assistance for low-income
residents is a defined program with service and payment limits. The Clinic will not be responsible for bills which I
may incur outside of the specified limits. I hereby swear that the above information is correct as stated. Falsifying
this information is a crime punishable by law.
_____________________________________
Signature
_____________________________________
Spouse’s name/signature if applicable
________________________________
Date
Income Eligibility 2015-2016
Family
size
1
2
3
4
5
6
7
8

Level APatient pays
5% of charge
0-11,770
0-15,930
0-20,090
0-24,250
0-28,410
0-32,570
0-36,730
0-40,890
Level B-Patient pays Level C-Patient pays
10% of charge
15% of charge
11,771-15,693
15,931-21,240
20,091-26,787
24,251-32,333
28,411-37,880
32,571-43,427
36,731-48,973
40,891-54,520
15,694-19,617
21,241-26,550
26,788-33,483
32,334-40,417
37,881-47,350
43,428-54,283
48,974-61,217
54,521-68,150
Level D-Patient pays
20% of charge
Patient pays
100% of charge
19,618-23,540
26,551-31,860
33,484-40,180
40,418-48,500
47,351-56,820
54,284-65,140
61,218-73,460
68,151-81,780
23,541+
31,861+
40,181+
48,501+
56,821+
65,141+
73,461+
81,781+
(**Patient shall pay 5% at Level A, 25% at Level B, 50% at Level C, and 75% at Level D, for pharmacy coverage.)