Sliding Fee Discount Program Policy 

All patients seeking health care services at Branches of Growth Mental Health Counseling, PLLC are
assured that they will be served regardless of ability to pay. No one is refused service because of lack of
financial means to pay. This program is designed to provide free or discounted care to those who have no
means, or limited means, to pay for their medical services (uninsured or underinsured). Branches of
Growth offers a Sliding Fee Discount Program to all who are unable to pay for their services. Branches of
Growth will base program eligibility on a person’s ability to pay and will not discriminate on the basis of
an individual’s race, color, sex, national origin, disability, religion, age, sexual orientation, or gender
identity. The Federal Poverty Guidelines are used in creating, and annually updating, the sliding fee
schedule to determine eligibility.
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PROCEDURE: The following guidelines are to be followed in providing the Sliding Fee Discount Program.

1. Notification: Branches of Growth will notify patients of the Sliding Fee Discount Program by:
                • Payment Policy - Information will be available to all patients at the time of service.
                • Notification of the Sliding Fee Discount Program will be offered to each patient upon admission.
                • Sliding Fee Discount Program application will be included with collection notices sent out by
Branches of Growth.
                • An explanation of our Sliding Fee Discount Program and our application form are available on
Branches of Growth’s website.
                •Sliding Fee Discount Program signage appears in the clinic waiting area.

2. Request for Discount: Requests for discounted services may be made by patients, family members,
social services staff, or others who are aware of existing financial hardship. The Sliding Fee Discount
Program will only be made available for clinic visits. Information and forms can be obtained from the
Front Desk.

3. Administration: The Sliding Fee Discount Program procedure will be administered through the
Business Office Manager or designee. Information about the Sliding Fee Discount Program policy and
procedure will be provided to patients. Staff are to offer assistance for completion of the application.
Dignity and confidentiality will be respected for all who seek and/or are provided health care services.

4. Completion of Application: The patient/responsible party must complete the Sliding Fee Discount
Program application in its entirety. Staff will be available, as needed, to assist the patient/responsible
party with applications. By signing the Sliding Fee Discount Program application, persons are confirming
their income to Branches of Growth as disclosed on the application form.

5. Eligibility: Discounts will be based on income and family size only.
                   a. Family is defined as: Individuals of a household both traditional and non-traditional families
that are tied together financially or a group of two people or more (one of whom is the householder) related by birth, marriage, or adoption and residing together; all such people (including related subfamily
members) are considered as members of one family. Branches of Growth will accept non-related
household members when calculating family size.
                    b. Income includes: gross wages; salaries; tips; income from business and self employment;
unemployment compensation; workers' compensation; Social Security; supplemental security income;
veterans' payments; survivor benefits; pension or retirement income; interest; dividends; royalties;
income from rental properties, estates, and trusts; alimony; child support; assistance from outside the
household; and other miscellaneous sources.

6. Income Verification: Applicants may provide one of the following: prior year W-2, two most recent pay
stubs, letter from employer, or Form 4506-T (if W-2 not filed). Self Employed individuals will be required
to submit details for the most recent three months of income and expenses for the business. Adequate
information must be made available to determine eligibility for the program. Self-declaration of Income
may be used. Patients who are unable to provide written verification may provide a signed statement of
income.

7. Discounts: Those with incomes at or below 100% of poverty will receive a full 100% discount for health
care services. Those with incomes above 100% of poverty, but at or below 200% of poverty, will be
charged a nominal fee according to the attached sliding fee schedule. The sliding fee schedule will be
updated during the first quarter of every calendar year with the latest Federal Poverty Line Guidelines.

8. Nominal Fee: Patients with incomes above 100% of poverty, but at or below 200% poverty will be
charged a nominal fee according to the attached sliding fee schedule and based on their family size and
income. However, patients will not be denied services due to an inability to pay. The nominal fee is not a
threshold for receiving care, and thus is not a minimum fee or co-payment.

9. Waiving of Charges: In certain situations, patients may not be able to pay the nominal or discount fee.
Waiving of charges must be approved by Branches of Growth designated official. Any waiving of charges
should be documented in the patient’s file along with an explanation.

10. Applicant Notification: The Sliding Fee Discount Program determination will be provided to the
applicant(s) in writing, and will include the percentage of Sliding Fee Discount Program write off, or, if
applicable, the reason for denial. If the application is approved for less than a 100% discount or denied,
Branches of Growth will work with the patient and/or responsible party to establish payment
arrangements. Sliding Fee Discount Program applications cover outstanding patient balances for six
months prior to application date and any balances incurred within 12 months after the approved date,
unless their financial situation changes significantly. The applicant has the option to reapply after the 12
months have expired or anytime there has been a significant change in family income. When the
applicant reapplies, the look back period will be the lesser of six months or the expiration of their last
Sliding Fee Discount Program application.

11. Refusal to Pay: If a patient verbally expresses an unwillingness to pay or vacates the premises
without paying for services, the patient will be contacted in writing regarding their payment obligations.
If the patient is not on the sliding fee schedule, a copy of the sliding fee discount program application will
be sent with the notice. If the patient does not make an effort to pay or fails to respond within 60 days,
this constitutes refusal to pay. At this point in time, Branches of Growth can explore options not limited to, but including offering the patient a payment plan, waiving of charges, or referring the patient to
collections.

12. Record Keeping: Information related to Sliding Fee Discount Program decisions will be maintained
and preserved in a centralized confidential file located in the Business Office Manager’s Office, in an
effort to preserve the dignity of those receiving free or discounted care.
                          a. Applicants that have been approved for the Sliding Fee Discount Program will be logged in
Branches of Growth’s practice management system, noting names of applicants, dates of coverage and
percentage of coverage.
                          b. The Business Office Manager will maintain an additional monthly log identifying Sliding Fee
Discount Program recipients and dollar amounts. Denials and applications not returned will also be
logged.

13. Policy and Procedure Review: The Sliding Fee Schedule will be updated based on the current Federal
Poverty Guidelines. Branches of Growth will also review possible changes in our policy and procedures
and for examining institutional practices which may serve as barriers preventing eligible patients from
having access to our community care provisions.

14. Budget: During the annual budget process, an estimated amount of Sliding Fee Discount Program
service will be placed into the budget as a deduction from revenue.

Do I qualify? 

View fee schedule

Sliding Fee Application