Financial Assistance Application
Submission of a sliding scale request does not guarantee approval. Financial documentation is required, and by applying, you confirm that all information provided is accurate and complete.If approved, sliding scale rates are granted for a limited number of sessions or for a specific period of time. Continued eligibility requires reapplication and review.Sliding scale availability and approval rates are based on current industry demand and may be adjusted at any time.Clients with active insurance are not eligible for sliding scale rates when their provider is in-network with their insurance plan.
Patient Information
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Provider Name
*
Annual Household Income
*
Household Size
*
Please Select
1
2
3
4
5
6
7
8
9
10
Change in Financial Status
*
Please Select
Recent Job loss
Recent reduction in pay/hours
Separation from partner/spouse
Unexpected medical expenses
Death in the family
New disability or illness
Business Closure or loss
Divorce Proceedings
Reason for Request
*
Sign Form
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submitter Name (if different from patient)
First Name
Last Name
Continue
Continue
Should be Empty: