DUI/SUD PROGRAM ONBOARDING FORM

Insurance & Payment Policy

We will make every effort to use your insurance for payment of services. However, this does not guarantee that your insurance company will cover all or any portion of the cost of services. If your insurance denies payment for any reason, you will be responsible for the remaining balance at our lower “Cash Pay” rate. Payment in full is required at the commencement of your program.

Please note that certification cannot be issued for any program or class until all associated balances are paid in full.

If you lose or discontinue insurance coverage during your program, you will be responsible for all remaining costs at the “Cash Pay” rate.

Medicaid, Medicare, or Veteran Benefit Plans

The client may be covered under the Illinois Department of Public Aid – Medical Assistance Program (Medicaid), Medicare, or an approved Veteran benefit plan. The client must present a valid insurance or benefit card at each appointment. All services not covered by the plan will be billed to the client at either the usual rate or the applicable subsidized “Cash Pay” fee.

Proof of active coverage must be verified before scheduling or continuation of services.

DUI PROGRAM PAYMENT PLAN POLICY & FINANCIAL AGREEMENT

Program Payment Terms
All DUI clients are financially responsible for the cost of their evaluation, education, and treatment services.
To maintain program eligibility and compliance with Illinois Secretary of State reinstatement requirements, all fees must be paid according to the terms outlined below.

Down Payment & Convenience Fee
A 20% down payment of the total program cost is required before services begin.
A 5% convenience fee will be added to all payment plan balances.
The remaining balance must be paid in accordance with the payment plan schedule selected at intake.

Payment Plan Options
Payment plans may be structured based on the total program length and client preference.

Available options include:

2 Payments
4 Payments
8 Payments

12 Payments (Only available for Level III and IV) 
16 Payments - (Only available for Level III and IV) 

Payment dates will be established at intake and documented in your financial agreement.

Early Payoff Rewards
Clients who pay their balance in full before program completion may qualify for early payoff rewards or fee reductions at the discretion of AFCC administration.

Late Payments
A $20 late fee will be applied to each missed or delayed payment.
Repeated missed payments or non-payment may result in suspension from classes, delay in certificate issuance, or termination from the program until the account is brought current.

Accepted Forms of Payment
We accept the following forms of payment:
💵 Cash 🏦 Zelle 💳 Credit/Debit Card 📱 Venmo 💸 Cash App 🍎 Apple Pay 💻 PayPal

Sliding Scale Options
AFCC offers Sliding Scale Payment Plans based on gross household income to ensure fair access to treatment.
To apply, clients must submit proof of income (such as pay stubs or tax returns).
Eligibility is reviewed during intake and determined according to federal poverty guidelines and AFCC policy.

I hereby certify that all information provided in this onboarding form is true, accurate, and complete. I understand that knowingly providing false or incomplete information may constitute a violation of Illinois Administrative Code 77, Part 2060. I may impact my participation, reporting, or completion status within the DUI program.