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IREDELL COUNTY HOME HEALTH AGENCY
COMPUTATION OF FEE
Patient
Name:
Address:
Step 1.
Determine total annual
income
$
Step 2.
Determine percentage of
fee based
X
on family size and annual income
(see scale
Step 3.
Fee for each discipline
based on
percentage (not to exceed
charge for
each discipline)
Charges
Fees
Nag.
$37.00
Nsg.
$
HHA
$28.00
HHA
$
PT
$45.00
PT
$
ST
$45.00
ST
$
MSW
$45.00
MSW
$
BOA n X184