Sliding Fee Program Application

Sliding Fee Program Application

Complete the application below. Once your application for the Sliding Fee Program is approved, you will be notified via email to complete the New Patient Registration Form to get started with scheduling. On the New Patient Registration Form be sure to select "Sliding Scale" as your payment option.
Important Information Regarding the Washington Area Clinical Center Sliding Fee Program:

Washington Area Clinical Center (WACC) is committed to providing affordable mental health care services. Our Sliding Fee Program offers reduced rates based on your household income and size.

To ensure a fair and sustainable program, we require accurate information from all applicants.

Here's what you need to know:

Application Disclosure: The information you provide on your application, including family size (as reported on an IRS tax return) and gross annual income from all sources (wages, Social Security, SSI, unemployment, etc.), must be true and complete to the best of your knowledge.

Verification: WACC may request additional documentation to verify your eligibility.

Reporting Changes: It's your responsibility to promptly notify us of any changes to your insurance, household income, or family size.

Maintaining Program Integrity: We rely on the information you provide to determine your sliding fee discount. If there's reason to suspect inaccurate or incomplete information, or a lack of reported changes, WACC may review your financial status.

Consequences of Misrepresentation: If false information is discovered, you may be responsible for reimbursing any discounts received and potentially lose eligibility for the program.

We appreciate your cooperation in ensuring the Sliding Fee Program remains accessible to those who need it most.

If you have any questions, please don't hesitate to contact our office.

Demographics
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
If eligible, please provide us with your Medical Assistance Number.
YesNo

Financial Assistance Eligibility

Eligibility for Washington Area Clinical Center’s sliding fee scale financial assistance is based on income levels relative to the federal poverty guidelines published annually and the number of individuals living in your household. Certain sources of income are excluded from the calculation of household income (see below).
Household Demographics

Please list the following members of your household: self, spouse/significant other, and children (including step-children and legally adopted children up to 18 years of age) and list ALL income earned by the listed members.
Household Member*
If no members of your household earn income used to calculate eligibility for the sliding fee scale, please check the box below and the appropriate box within the Means of Support.
I attest that all members of my household have NO INCOME.
Disability PaymentsChild Support PaymentsWorker's CompensationTemporary Cash AssistanceSSI (Supplemental Security Income)Social Security DisabilityAssistance by Other Family MembersOther
Other:*

Proof of Income Documentations
Current Pay Stub (within 90 days)W-2 Tax FormTax Return Form (1040, Line 9)Social Security NoticeUnemployment NoticeLetter from Employer
Current Pay Stub (within 90 days)

Cancelof
W-2 Tax Form

Cancelof
Tax Return Form (1040, Line 9)

Cancelof
Social Security Notice

Cancelof
Unemployment Notice (For Six Months)

Cancelof
Letter from Employer

Cancelof

I certify under penalty of perjury, that the above statements are true, accurate and complete to the best of my knowledge and belief.*

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Input the values and then press Enter for calculations.
Monthly: # in household: Members Gross Income Income multiplied by Insert: 12 = Total Amount
Weekly: # in household: Members Gross Income Income multiplied by Insert: 52 = Total Amount
Bi-Weekly: # in household: Members Gross Income Income multiplied by Insert: 26 = Total Amount
Annual: # in household: Members Gross Income Income multiplied by Insert: 1 = Total Amount
Level 1Level 2Level 3
Should be Empty:

Sliding Fee Program Application

Demographics

Financial Assistance Eligibility

Household Demographics

If no members of your household earn income used to calculate eligibility for the sliding fee scale, please check the box below and the appropriate box within the Means of Support.

Proof of Income Documentations

For Office Use Only