Sliding Scale Fee Form
This form is used to determine a client’s eligibility for reduced service fees based on financial circumstances.
Client Name
*
First Name
Last Name
Name of Parent/Guardian Completing Form (if applicable)
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you currently covered by health insurance?
*
Yes, but I have not submitted it yet.
I have health insurance and have submitted the required information to 180 RED.
No, I do not have health insurance.
Please include a copy of the front of your insurance card if you have one and have not yet submitted it.
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Please include a copy of the backof your insurance card if you have one and have not yet submitted it.
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My total household size (please include all individuals living in your household who share income and expenses, such as yourself, spouse/partner, dependents, and any other persons financially supported within the home.)
*
I have submitted three of the most recent pay stubs for all individuals in my household who contribute financially.
*
Yes, that has been completed.
No, I have not yet, but I understand this is required to be considered for the sliding fee scale.
I do not have any pay stubs to provide because I am currently unemployed.
Please upload your first pay stub here if you have not already submitted it. Make sure it is one of your three most recent pay stubs. If you are unemployed, please leave this section blank.
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Please upload your second pay stub here if you have not already submitted it. Make sure it is one of your three most recent pay stubs. If you are unemployed, please leave this section blank.
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Please upload your third pay stub here if you have not already submitted it. Make sure it is one of your three most recent pay stubs. If you are unemployed, please leave this section blank.
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Do you receive any other monthly income, such as child support, alimony, Social Security benefits, or unemployment benefits?
*
Yes
No
I understand that the company’s late cancellation and missed appointment policy still applies while I am enrolled in this program. I acknowledge that the late cancellation fee is $50 and the no-call/no-show fee is $75. A no-call/no-show is defined as arriving more than 15 minutes past the appointment time without contacting your clinician.
*
I understand and agree
I understand that, if approved, I will be required to submit documentation every three months from my approval date to remain eligible for this program, and that 180 RED reserves the right to revoke an approved application at any time, with notice of the reason provided.
*
I understand and agree
By signing this document, I certify that the information provided above is true and accurate as of the date of this form. I understand that failure to make an agreed-upon payment may result in removal from the sliding fee scale program and that I may be charged the full insurance or provider rate.
*
I understand and agree
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
*
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