BreatheWorks Application for Financial Hardship Assistance - Sliding Scale
BreatheWorks Speech Therapy understand that medical treatment can be difficult to afford. We do not believe that finances should stand in the way of someone’s opportunity to live a healthy life. Clients who are experiencing financial hardship and have an out-of-network insurance provider/no insurance may apply for financial assistance by completing and submitting this form. Upon meeting our criteria, taking into account family size and income, applicants may qualify for reduced treatment cost. Please note that patients receiving a Sliding Scale discount will be considered private pay, and payment will be due at the time of service. Our clinic will not submit claims to insurance. Our team will review your request and contact you within 14 days of receiving the application. Please don’t hesitate to reach out to us with any questions you may have. Thank you for choosing BreatheWorks to be a part of your treatment team.
Patient Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Guardian(s) Name (if a minor)
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Phone Number
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Email Address
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Address:
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What consideration are you requesting?
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Please Select
Discount
Significant Reduction
Are you currently receiving any type of benefits from local, county, state or federal government? If yes, please describe.
*
Are you and/or your partner currently employed?
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Please Select
Full time
Part time
No
Do you own your own home?
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Please Select
Yes
No
Number of people in household:
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Total household income (before taxes):
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Supporting Documentation
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Most recent pay stubs (last two months)
Tax return (most recent year)
Unemployment /Disability/Social Security Benefits Statement
Other proof of income
Source(s) of Income:
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Employment
Self-Employement
Social Security
Disability
Unemployment
Other
Please describe all familial, financial or social circumstances which make it difficult to afford treatment?
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Patient CertificationI certify that the information provided is true and complete to the best of my knowledge. I understand that providing false information may result in denial or termination of discounted services.
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Print Name
Today's Date
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Month
-
Day
Year
Date
Signature
*
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Sliding Scale Eligibility (Office Use Only):
Household size:
Verified Monthly Income:
Federal Poverty Level:
Discount Level Approved:
Approved Fee (per visit)
Reviewed by: Date:
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