By submitting the following, you are agreeing to all terms in our Voucher program.
PAYMENT TERMS
- The voucher amount is accepted as payment in full or partial payment for the session.
- Balance billing is permitted: the provider may charge the client the remaining balance up to their standard session fee.
- Payment is issued within 30 days of a complete session confirmation submission.
- Annual voucher payments to non-partner providers are capped at $400; any income over $600 requires a completed W-9.
THIS VOUCHER DOES NOT COVER
- No-show fees, late cancellation fees, or administrative fees of any kind.
- Telehealth platform fees billed as separate charges.
- Services rendered before the voucher was issued.
- Services rendered after the voucher expiration date.
- Inpatient, residential, or crisis stabilization services.
- Services by an unlicensed or provisionally licensed provider without proper supervision disclosure.
- Sessions already reimbursed in full by insurance (no double-billing).
PROVIDER REQUIREMENTS
- Hold an active Arizona license in good standing at the time of service.
- Not be currently excluded from Medicare, Medicaid, or any federal/state healthcare program.
- Have not had a license revoked, surrendered, or suspended within the past three years.
- Provide services within the licensed scope of practice.
- For telehealth: provider must be licensed in AZ and client must be physically located in AZ at the time of service.
PROVIDER ACKNOWLEDGMENT
By submitting this form, I acknowledge and agree that:
- I have read and understand the voucher terms above, including the list of services this voucher does not cover.
- I meet all provider requirements listed and will provide services within my licensed scope of practice in Arizona.
- I performed a valid session within 30 days of the service date.
- I will not submit a payment request for a session that did not occur, falsify a date of service, or misrepresent my licensure.
- I understand that voucher fraud may result in reporting to the Arizona licensing board, permanent removal from Foundation programs, repayment demand, and civil action.
- I understand the Foundation may contact the client to verify the session occurred before payment is issued.