Sliding Scale Discount Program Application

Sliding Scale Discount Program Application
Thank you for considering Light Counseling for your mental health needs!

To ensure our clinically excellent and distinctly Christian services are made reasonably available to clients in our communities, we are proud to offer a Sliding Scale Discount Program. Fees are calculated based on Family Size and Income that is calculated from the Federal Poverty Guidelines. By signing below, you agree to the following:
- Submitting this application DOES NOT mean you are a participant in the Sliding Scale Program. The submitted application will go to Light Counseling's billing team for review and a decision will be issued within 30 business days. If approved, this Sliding Fee Discount Program application will cover outstanding balances for one month before the application date's effective date and any balances incurred 12 months after the approved date unless their financial situation changes significantly.
- All Sliding Fee Discount Program participants must re-apply ANNUALLY with current proof of income.
- Everything requested in this application is required for us to meet government and insurance regulations regarding our billing practices for reduced rates.
- Due to the varying requirements of commercial and government-sponsored insurance payers, you are not eligible to participate in the Sliding Scale Discount Program if you plan to use your insurance.
- The Federal Poverty Guidelines, household size, and income are used in creating and annually updating the sliding fee discount schedule (SFDS) to determine eligibility; however, Light Counseling Inc. may amend the SFS at our discretion.
- The discount will apply to all services received at this clinic, but not those services or equipment purchased from outside, including reference laboratory testing, drugs, x-ray interpretation by a consulting radiologist, and other such services. You must complete this form every 12 months or if your financial situation changes.
By signing below, you acknowledge that you understand the application instructions above and may also be required to complete additional documentation and consent to participate in the Sliding Scale Program and become a client of Light Counseling Inc. and its affiliates
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Are you signing on behalf of the client?*

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Name of Signer*

First NameLast Name
Relationship to the Client
Which state are you located in?*
Are you currently a client of Light Counseling?*

YesNoPrevious Client

How many members (including yourself) live in your household?*
Household member can be family and non-family members.

Income

	Gross Wages, Salaries, Tips, etc.	Income From Business and Self-Employment	Unemployment Compensation, Workers Compensation, Social Security, Supplemental Security Income, Veterans' Payments, Survivor Benefits, Pension or Retirement Income	Interest, Dividends, Royalties, Income from Rental Properties, Estates and Trusts, Alimony, Child Support, Assistance from Outside the Household, and Other Miscellaneous Sources
Self
Others
TOTAL

Total Gross Income*
If you are experiencing financial hardship that is not reflected in your household income (e.g., unexpected medical bills, loss of employment, disability), please briefly describe:

Proof of Income

You are required to submit all proofs of income to complete your application.
In order for your application to be considered, you are required to provide at least one of the following. If additional family members are being claimed in this application, there must also be one of the following documents for each family member who is over 17 years of age. Please select all proofs of income to attach with your application:*

Prior year's W-2Two (2) most recent pay stubsA letter from your employer(s), and/orForm 4506-T (if W-2 was not filed).Self-Declaration of Income Statement: If you are unable to provide the required documentation, you must provide the reason(s) below on your self-declaration and sign to certify that the information is accurate. If you are self-employed, you must also submit details of your business’s income and expenses for the most recent three months. Adequate information must be provided to determine eligibility for the program.
Please upload the copy of your document(s)*

Cancelof

Disclosure
By submitting this application, you are affirming that all information provided in relation to this application is true and accurate to the best of your knowledge. In the event that it is proven that any information provided is false, the following consequences shall apply:
- The patient shall forfeit any discounts received under the SFSD
- The patient or patient's guarantor shall be liable for any additional costs incurred by Light Counseling Inc. and it's staff due to the false information.
- Light Counseling Inc. reserves the right to pursue legal action for any damages caused by the false information.
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Sliding Scale Discount Program Application

Applicant / Client Information

Proof of Income

Disclosure