• DECLARATION OF INCOME AND SERVICE COST

    All questions should be answered; those not applicable must be marked with NA.

  • I understand that a portion of the cost of services provided to me is being subsidized by public funds. As required by eligibility guidelines. I hereby certify that my personal and household income for the past 12 months was $*

  • I further understand and agree that this amount and the dates that I receive service may be subject to further verification by the Detroit Wayne Integrated Health Network (DWIHN) or its treatment contractors. Additionally, this information will be reviewed every 90 days after admission to treatment.
  • I understand that the co-payment portion of my service cost is my responsibility to pay.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • WAIVER OF CLIENT FINANCIAL ABILITY TO PAY FOR SERVICES

  • CLIENT DATE OF BIRTH:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • I am requesting that the ability to pay criteria established for this client be waived for the following reasons*
  • Should be Empty: