Optum Scholarship Request Form

Optum Scholarship Request Form
Plymouth Psych Group has established a scholarship fund strictly for families with United Health Care insurance seeing a pre-licensed therapist and need to request reduced or waived appointment fees.

All requests are confidential and will be considered on a case-by-case basis.
Name *

First Name Last Name
Email *
Phone Number *

Area Code Phone Number
Please select: *

I am experiencing a financial hardship and can pay a reduced appointment fee. I am requesting to waive appointment fees due to a financial hardship.
If you selected to pay a REDUCED FEE in the question above, please estimate the amount that you would be able to pay per session:
Please describe the nature of your hardship. *
By completing and signing this form, I affirm and certify that the information and questions answered herein are complete, true and correct to the best of my knowledge.
Patient Signature (or guardian if under age 18)

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