Financial Assistance & Insurance Screening

Financial Assistance & Insurance Screening

Brain & Heart Healing, PLLC
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Client Email*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Household Size*
Gross Annual Income*
Proof of Income (Tax Return or Last 3 Pay Stubs)*

Cancelof
Financial Hardship / Extenuating Circumstances
Tell us about any financial hardships not shown on your tax return (e.g., job loss, medical debt, or high cost of living).
2026 Federal Poverty Level (FPL)
Final FPL %
2026 Federal Poverty Level (FPL) Tier Level:
Estimated Tier A: 0% – 100% FPL
Estimated Benefit: Tier A (Full Discount) Based on your household size and income, you qualify for our highest discount.
- Your Fee: A nominal charge of $20.00 per session.
- Next Step: Please ensure you have uploaded your proof of income below for final verification by our staff.
Final tier determination is subject to clinical review of your income documentation.
Estimated Tier B: 101% – 133% FPL
Estimated Benefit: Tier B (75% Discount) Based on your household size and income, you qualify for a 75% discount on our standard rates.
- Your Fee: Approximately 25% of the standard session rate.
- Next Step: Final fee will be confirmed upon review of your income documentation.
Final tier determination is subject to clinical review of your income documentation.
Estimated Tier C: 134% – 166% FPL
Estimated Benefit: Tier C (50% Discount) Based on your household size and income, you qualify for a 50% discount on our standard rates.
- Your Fee: Approximately 50% of the standard session rate.
- Next Step: Please upload your 1040 Tax Return or pay stubs below to finalize this rate.
Final tier determination is subject to clinical review of your income documentation.
Estimated Tier D: 167% – 200% FPL
Estimated Benefit: Tier D (25% Discount) Based on your household size and income, you qualify for a 25% discount on our standard rates.
- Your Fee: Approximately 75% of the standard session rate.
- Next Step: Documentation is required below to apply this discount to your account.
Final tier determination is subject to clinical review of your income documentation.
Estimated Full Fee: Over 200% FPL
Estimated Benefit: Full Fee (Standard Rate) Based on the information provided, your household income is above the 200% Federal Poverty Level threshold.
- Your Fee: Our standard practice rate will apply.
- Note: If you have extenuating financial circumstances not captured here, please contact our office to discuss a payment plan.
Final tier determination is subject to clinical review of your income documentation.
I am currently enrolled in Medicaid or CHIP.I am currently Uninsured.I have Private Insurance (PPO/HMO).I have Medicare.
Self-Declaration of Income / Support
Required only if reporting $0.00 income. Please explain how you pay for food, housing, and transportation (e.g., 'I live with my parents and they provide my meals').
Healthcare Marketplace

If you don't have health insurance through your employer, Medicare, Medicaid, the Children's Health Insurance Program (CHIP), or another source that provides qualifying health coverage, you can find coverage through the Marketplace.

Health Insurance Marketplace
Medicaid/CHIP Assistance:

Based on your status, you may be eligible for Texas Medicaid or the Children’s Health Insurance Program (CHIP). Would you like our office to send you information on how to apply? Enrollment in these programs provides more stable long-term care than a sliding scale alone.
Patient Attestation & Authorization

I hereby certify that the family size and income information provided is true and correct. I understand that:
- This information is used to determine my eligibility for a Sliding Fee Discount based on Federal Poverty Guidelines.
- I must provide proof of income (tax returns, pay stubs, or a letter of support) to finalize my discount.
- I am required to report any significant changes to my income or household size immediately.
- This application must be renewed every 12 months.
- I authorize Brain and Heart Healing, PLLC to verify this information as needed for program compliance.
Financial Hardship Statement for Insured Patients:

I understand that Brain & Heart Healing, PLLC is contractually required to collect copayments and deductibles as determined by my insurance provider. By submitting this application and providing proof of income, I am requesting an individualized 'Financial Hardship Waiver.' I understand that if approved, this waiver applies only to this specific period of care and is based on a good-faith determination of my current financial inability to pay the full out-of-pocket amount.
Signature*

Clear
Date*

MonthDayYear
Date
Waiver Status
Approved Tier/Discount
Internal Notes (Hardship Justification)
Clinic Director Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Financial Assistance & Insurance Screening

2026 Federal Poverty Level (FPL) Tier Level: