Sliding Fee Discount Program Policy

Branches of Growth Mental Health Counseling offers access to mental health counseling for patients who don’t have insurance or don’t have enough insurance, through a sliding fee discount program. These rates are based on the Federal Poverty Guidelines. This program can cover you for up to 12 months- a new application is required yearly or when your family size and income changes, whichever is sooner. 
The patient/responsible party must complete the Sliding Fee Discount Program application in its entirety. By signing the Sliding Fee Discount Program application, persons authorize the practice access in confirming income as disclosed on the application form. Providing false information on a Sliding Fee Discount Program application will result in all Sliding Fee Discount Program discounts being revoked and the full balance of the account(s) restored and payable immediately.
Income includes earnings, unemployment compensation, workers' compensation, Social Security, Supplemental Security Income, public assistance, veterans' payments, survivor benefits, pension or retirement income, interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources. Noncash benefits (such as food stamps and housing subsidies) do not count.
Applicants must provide the following: 

• Drivers license or proof of address (utility bill, passport, etc.) 
  
• Three most recent pay stubs. Self- employed individuals will be required to submit detail of 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 only be used in special circumstances. Specific examples include participants who are homeless. Patients who are unable to provide written verification must provide a signed statement of income, and why he/she is unable to provide independent verification. This statement will be reviewed and final determination as to the sliding fee percentage will be made. Self-declared patients will be responsible for 100% of their charges until management determines the appropriate category.
  

Discounted services would apply effective the date of application approval going forward. Information and forms can be obtained from the front desk, by calling our office number, or visiting our website. 


Renewal Applications: A patient who receives discounted services under this policy is required to submit an updated application every 12 months or if their financial situation changes. Failure to meet the annual financial information requirement may result in the patient no longer being eligible for the Sliding Fee Discount Program. If a patient is delinquent in meeting the updated annual application requirement, the practice will mail the patient a notice they are being terminated from the Sliding Fee Discount Program unless they submit the required financial information within the time frame (10 business days) noted in the letter.  If a patient does not submit the renewal information, they are no longer eligible for the discounted services per the date in the notice letter.
Information related to Sliding Fee Discount Program decisions will be maintained and preserved in a centralized confidential file located in the office of the designated staff member for the program, in an effort to preserve the dignity of those receiving free or discounted care.  

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Do I qualify? 

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