We can provide a sliding scale rate to any clients who qualify for our reduced rate services through hardship verification. To comply with federal regulations, in order to give you a reduced rate for services, it is necessary for us to obtain income verification. You must verify your income at least every year. Your adjusted gross income is used to figure the sliding scale rate.

To figure your adjusted rate per session:

Household adjusted gross income X .001 = Rate per session

No amount per session will be less than $45 or higher than regular session rate.

Example:

$45,000 per year = $45/session

$95,000 per year = $95/session

*One form of income verification must be attached to this application to be approved

If I have insurance coverage, I have selected to not use my insurance for my treatment. I understand that opting out of using my insurance means I must pay out of pocket for my treatment. I agree to give notice if I either obtain alternative insurance and/or decide that I would like my sessions billed to my insurance. I understand that if I opt out of using insurance I cannot use the payment of sessions towards my deductible because I have elected to opt out of using my insurance. I understand that if I choose to later use my insurance, my therapist is not liable and is not obligated to reimburse previous sessions where I have chosen to opt out of billing my insurance. My opt-in to use insurance will start from the day I notify my therapist of the change and cannot be backdated to previous sessions.

I do hereby affirm that the information provided on this application and income verification is true and correct to the best of my knowledge and understanding. I agree that any misleading, falsified information, and/or omissions may disqualify me from the Financial Hardship program. This could also subject me to penalties under federal law of falsifying information. I further agree to inform Grand Island Mental Health & Medical Clinic, LLC if there is a significant change in my income. I hereby acknowledge that I have read this information and understand in its entirety. Any questions have been answered.