Shining Star Sliding Fee Discount and Scholarship Application Form

Shining Star Sliding Fee Discount and Scholarship Application Form

Brighter Together, Inc. offers a Sliding Fee Discount Program and scholarship options designed to assist families in covering the costs of therapy services for children in Idaho. Eligibility is determined based on annual income, family size, and demonstrated need.Brighter Together, Inc. is committed to inclusivity and does not discriminate based on age, gender, race, sexual orientation, gender identity or expression, creed, religion, disability, or national origin.The program uses Federal Poverty Guidelines to establish the sliding fee schedule and determine scholarship awards for discounted services, ensuring that every child in Idaho has access to the therapy support they need.
Child's Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date

Have you applied for Idaho Medicaid or Katie Beckett Program?

YesNo
Many of our scholarship applicants have qualified for Medicaid in the past. If you have not qualified or were denied, could you briefly explain why? For reference, you can review the Idaho Medicaid family income limits here. https://healthandwelfare.idaho.gov/medicaid-program-income-limits Our scholarship program is designed to support families who do not qualify for Medicaid or similar programs and those whose insurance plans provide minimal coverage, leaving a significant financial burden for therapy costs

Additional Income

Total Monthly Income
Please Explain the program you are seeking assistance for and reasons for need.
Scholarship Amount Requested*
$
If you could make a partial payment what could you commit to comfortably monthly? *
Agreement:

If awarded a discounted rate or scholarship, you will be notified in writing. Rates are based on family size, income and current Federal Poverty Guidelines.

If receiving a sliding fee discount and there is hardship paying the discounted rates contact Brighter Together about other payment plan or options.

Approved sliding fee discounts or scholarships will have a limit on the amount of services or supports provided. Applicants may reapply for support at the conclusion of the service or support.

I agree to all of the Sliding Fee Discount and Shining Star Scholarship program requirements. I understand that providing false information of any kind will result in immediate termination of this agreement and I will be required to pay the agency’s full rate for each date of service provided. I certify that the family size and income information shown above is correct. I understand that it is the responsible party's obligation to pay any balance at each visit unless otherwise specified.
Should be Empty:

Family Information