Sliding Scale Fee Application

ALL INFORMATION IS CONFIDENTIAL

Definition of Household:

All members of a household who are related and pool financial resources are counted as one family if the arrangements are considered permanent and support greater than room and board is provided. Unrelated members of a household who are supporting one another financially are considered one family.

Definition of Income:

Income is defined as total cash before taxes from all sources, which can include:

Wages and Salaries
Receipts from self-employment after deductions for normal operating expenses
Regular payments through public assistance, social security, longevity, unemployment, strike benefits, military allotments, disability, rental income, regular support from an absent family member or someone not living in the household (includes child support), government or private pensions, and regular insurance or annuity payments
Income from dividends (including permanent fund), interest, rent royalties, or income from estates or trusts
Savings accounts (average balance of past 6 month’s activity, divided by 6 months’ equal monthly portion of income).

How do I qualify?

All applicants are asked to provide proof of household income and family size to qualify for discounted fees. If all required documentation is received and your application is approved, your discounted fees will be effective from the date on the application. There is a 30-day grace period from the date of your application to provide all of the necessary documentation.to the time the application needs to be returned. If the application is not returned within 30 days, you will be responsible for 100% of the charges. If the application is returned within 30 days and the patient qualifies on the scale, adjustments will be made starting with the date the application was provided to the patient. Information will be updated at least once every year or anytime your income, household size, and/or medical insurance status changes. It is your responsibility to keep an up-to-date sliding scale application with Aspen Ridge Counseling Center.

Responsible Party's Full Name (Must Match Intake Paperwork)*

First NameLast Name

Responsible Party's Email Address*

example@example.com

Responsible Party's Daytime Phone Number*

Please enter a valid phone number.

How Many Clients are you applying for?*

Up to 5 per application

Client 1 Name*

First NameLast Name

Client 1 Date of Birth*

Date

Client 2 Name*

First NameLast Name

Client 2 Date of Birth*

Date

Client 3 Name*

First NameLast Name

Client 3 Date of Birth*

Date

Client 4 Name*

First NameLast Name

Client 4 Date of Birth*

Date

Client 5 Name*

First NameLast Name

Client 5 Date of Birth*

Date

You must provide proof of income to qualify for the discount schedule. This information must be updated at least annually, and any time your household income, size, and/or medical insurance status changes. You will be responsible for the full amount of the visit as stated and the discount will not be applied to your account until you provide Aspen Ridge Counseling Center the required proof of income. If proof of income is provided, and if you are eligible, the discount will be applied retroactively starting from the application date and all following visits will be discounted for 1 year from the application date, after which, you will need to reapply. Proof of income includes prior year completed income tax forms, pay stubs from the last three months, unemployment or other benefits income receipts, and/or letters of income verification from two other individuals or from the employer(s). List your name and the names of ALL individuals who live with you. Name, Relationship, Age, Gender, Date of Birth, Annual Income, and Employer.

	Name	Relationship	Gender	Date of Birth	Annual Income	Employer Name
Person 1
Person 2
Person 3
Person 4
Person 5
Person 6
Person 7
Person 8
Person 9
Person 10

Please list ALL that you, and those living in your household have received in the last 3 Months (Please enter 0 in any rows that do not apply, a number is required in every box to be able to submit the form)*

	Dollar Amount/Dollar Equivalent
Unemployment
Social Security
Pension/Retirement
Rental Income/Dividends
Interest
Spousal Support
Child Support
Foster Care
Public Assistance (WIC, SNAP, etc.)
Self Employment (Net Amount, including 1099)
Workers Comp Benefits
Disability Benefits
W-2 Employers
Other

Please enter the total amount of money earned by all in your household in an average Month*

Are you currently employed?*

Is your work seasonal only? *

If you are not working, how are you meeting your monthly expenses?*

If "Other," please explain*

Do you have health insurance?*

If "Yes," who is your insurance provider?*

Insurance ID Number*

Subscriber Name and DOB*

**Please submit a picture the front and back of your insurance card in the file upload below with your other supporting documentation**

Please upload all of your supporting documentation including proof of income here*

I authorize all government agencies, employers, and any companies, agencies, or persons listed herein to provide information about me to Aspen Ridge Counseling Center LLC, the State of Utah, and/or the federal government. I also authorize Aspen Ridge Counseling to disclose this information to agencies, third-party payers, and other health care providers as necessary to qualify me for reduced fees. I certify that the statements regarding the persons and income in my household are true and correct to the best of my knowledge. I further understand if any information is found to be inaccurate, I may be denied a discount and/or subject to legal action for knowingly providing false information. I agree to notify Aspen Ridge Counseling of all changes in income, address, living arrangements, number of household members, and/or other circumstances. I understand that the information given above will be kept confidential except for the purposes noted above and not be released without my written permission. I also understand that if I do not agree with any decision made concerning this application, I have the right to ask in writing for a review by the Owners.

Signature*

Please type the name signed above*

Today's date*

Date

Aspen Ridge Counseling Center Sliding Scale Fee Application