Sliding Fee Application

Sliding Fee Application

The Luminous Mind follows income guidelines set by the Minnesota Department of Human Services.
Client Information*

First NameLast Name
This form is being completed for*

Current clientNew client
Birth Date

MonthDayYear
I am currently seeking the following services:*

TherapyComprehensive EvaluationBoth
Please indicate the name of the provider that you are working with or would like to work with:
Leave blank if this is not relevant.
Client's Date of Birth*
Select the option that best describes your situation*

I am not insured and would like to self-pay.I am insured but the provider I want to see is out of network with my insurance.I have in-network insurance and choose to self-pay (e.g., privacy reasons).I have in-network insurance and am completing this form to reduce the cost of non-covered services related to receiving a Comprehensive Evaluation.
I have insurance coverage with insurance company*
Income Information
For clients with in-network insurance:

If you are completing this form to determine whether you qualify for a reduction in the cost of covered services:

1. You are not eligible for any discounts and must pay standard service rates (see Finanacial Agreement for fee schedule).

2. You must complete an Insurance Opt-Out Form (contact AJ Bantley at contact@theluminousmind.com for this form).
As you will be utilizing you in-network coverage, please provide the information below to help assess whether you are eligible for a reduction of the $750 non-covered services fee.
Annual Household Income in 2024*
HOUSEHOLD INCOME INCLUDES WAGES AND INVESTMENT RETURNS OF ALL INDIVIDUALS 18 YEARS AND OLDER.
Number of People in Household*
SELECT "1" IF IT IS ONLY YOU IN THE HOUSEHOLD.
Please upload a copy of your 2024 tax return or current pay stubs*

Cancelof
I am aware that:
- I am responsible for providing accurate information regarding my income and insurance.
- I am responsible for submitting accurate proof of income.
- I am responsible for completing a Payment Authorization Form on the client portal and to update it when necessary.
- I will be required to complete this form annually.
- In the case of a no-show or late cancellation, I am responsible for paying the no-show fee in its entirety (i.e., fee will not be reduced).
- If I obtain insurance coverage, I understand that I am responsible for sharing that information with The Luminous Mind and that The Luminous Mind reserves the right not to provide back billing.
This form is being completed as undersigned client (or their legal guardian in case of minor) has elected to private pay for mental health services to be rendered at The Luminous Mind. I understand that upon submitting this information, I will be contacted regarding cost of services based on information that I have provided. I acknowledge that if information submitted by me is found to be false, I will be liable for the full cost of services.*

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Sliding Fee Application

Income Information