Mālama I Ke Ola Health Center Discount Program

The Mälama I Ke Ola Health Center is a federally qualified health center providing YOU with medical and dental
care and counseling services. We have been fortunate to receive federal funding to meet our community’s healthcare
needs. Our Sliding-Fee Discount program provides a discount for YOU if you qualify under income guidelines.
It is based upon your household size and total gross income and YOU could qualify for a discount on clinic
and counseling services. This discount may be applied to insurance co-pays, thus reducing the amount you have
to pay.

The discount applies to the health center services but there are some nominal fees that we will charge so that
we are able to meet the costs of providing the care YOU need when YOU need it! The nominal charge is $25 for
clinical, $40 for dental and $10 for counseling services. This nominal fee includes on-site laboratory services and
medicines you receive from us. Please inquire at the front desk if you have questions about the discounts you can
receive.

Please submit one of the following as proof of income:

• Your most recent paycheck stub;
• Your most recent federal income tax 1040 form (including Schedule C if self-employed);
• A letter from your employer indicating earnings (signed, with employer’s Tax ID#);
• Social Security, Unemployment, Retirement Benefits statements or pay stubs; or
• Your most recent bank statement.

Your proof of income is good for one year and must be updated annually. Applications lacking required documentation
may disqualify you from receiving a discount.

If you make a full payment at the time of your visit you will receive a Prompt Pay discount of 50%

Mälama I Ke Ola Health Center can provide assistance with QUEST (Hawai‘i Medicaid) applications and urgent
care prescription medications, and referrals for other pharmaceutical assistance programs. Please ask to speak
with a Member Services Representative if YOU believe you qualify for assistance under any of these special
programs.

ANY INCOME INFORMATION YOU PROVIDE IS STRICTLY CONFIDENTIAL

Download Forms Below