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Sliding Fee Discount Application Patient Information

Today’s Date:

First Name:

Middle:

/

/

Last:

Other names:

Home Address:

City:

State:

Zip:

Mailing Address:

City:

State:

Zip:

Home Phone #: (

)

Date of Birth:

/

Marital Status:

Single

/

Home Phone #: ( Social Security #

In a relationship

-

Married

)

-

-

Divorced

Do you have insurance? (circle one) Separated

Household Size Name

Date of Birth / / / / / / / / / /

Social Security Number -

Household Income Name

Amount

Frequency (Circle one)

You

$

Weekly Monthly Yearly

Spouse

$

Weekly Monthly Yearly

Children

$

Weekly Monthly Yearly

Other

$

Weekly Monthly Yearly

$

Weekly Monthly Yearly

$

Weekly Monthly Yearly

TOTAL Other Income

You

Spouse

Children

Employer:

Other

Subtotal

Yes

Widowed

It is the policy of Cornerstone Family Therapy to provide essential services regardless of the patient’s ability to pay. Discounts are offered based on family size and annual income. Please complete the following information and return Cornerstone Family Therapy at Betty@cornerstonefamilytherapy.org or fax to (574) 281-4412 to determine if you or members of your family are eligible for a discount. This form must be completed yearly or if your financial situation changes.

Sliding Fee Scale:

Social Security

A – 80% Discount

Public Assistance Retirement Pension

B – 60% Discount

Food Stamps

C – 40% Discount

Child Support, Alimony Interest Income

D – Nominal Fee

Other TOTAL

$

No


I do hereby swear or affirm that the information provided on this application is true and correct to the best of my knowledge and belief. I agree that any misleading or falsified information, and/or omissions may disqualify me from further consideration for the sliding fee program and will subject me to penalties under Federal Laws which may include fines and imprisonment. I further agree to inform Cornerstone Family Therapy if there is a significant change in my income. If acceptance to the sliding fee program is obtained under this application, I will comply with all rules and regulations of Cornerstone Family Therapy. I hereby acknowledge that I read the foregoing disclosure and understand it. Date:_________________________

Name (Print):__________________________________________________

Signature:____________________________________________________

Office Use Only Verification Checklist Identification/Address: Driver’s license, utility bill, employment ID, or other Income: Prior year tax return, three most recent pay stubs, or other Insurance: Insurance Cards

Yes

No

Patient Name: __________________________________________________________________ Approved Discount: _____________________________________________________________ Approved by: __________________________________________________________________ Date Approved: _________________________________________________________________


Sliding Fee Discount Application Patient Information

Today’s Date:

First Name:

Middle:

/

/

Last:

Other names:

Home Address:

City:

State:

Zip:

Mailing Address:

City:

State:

Zip:

Home Phone #: (

)

Date of Birth:

/

Marital Status:

Single

/

Home Phone #: ( Social Security #

In a relationship

-

Married

)

-

-

Divorced

Do you have insurance? (circle one) Separated

Household Size Name

Date of Birth / / / / / / / / / /

Social Security Number -

Household Income Name

Amount

Frequency (Circle one)

You

$

Weekly Monthly Yearly

Spouse

$

Weekly Monthly Yearly

Children

$

Weekly Monthly Yearly

Other

$

Weekly Monthly Yearly

$

Weekly Monthly Yearly

$

Weekly Monthly Yearly

TOTAL Other Income

You

Spouse

Children

Employer:

Other

Subtotal

Yes

Widowed

It is the policy of Cornerstone Family Therapy to provide essential services regardless of the patient’s ability to pay. Discounts are offered based on family size and annual income. Please complete the following information and return Cornerstone Family Therapy at Betty@cornerstonefamilytherapy.org or fax to (574) 281-4412 to determine if you or members of your family are eligible for a discount. This form must be completed yearly or if your financial situation changes.

Sliding Fee Scale:

Social Security

A – 80% Discount

Public Assistance Retirement Pension

B – 60% Discount

Food Stamps

C – 40% Discount

Child Support, Alimony Interest Income

D – Nominal Fee

Other TOTAL

$

No


I do hereby swear or affirm that the information provided on this application is true and correct to the best of my knowledge and belief. I agree that any misleading or falsified information, and/or omissions may disqualify me from further consideration for the sliding fee program and will subject me to penalties under Federal Laws which may include fines and imprisonment. I further agree to inform Cornerstone Family Therapy if there is a significant change in my income. If acceptance to the sliding fee program is obtained under this application, I will comply with all rules and regulations of Cornerstone Family Therapy. I hereby acknowledge that I read the foregoing disclosure and understand it. Date:_________________________

Name (Print):__________________________________________________

Signature:____________________________________________________

Office Use Only Verification Checklist Identification/Address: Driver’s license, utility bill, employment ID, or other Income: Prior year tax return, three most recent pay stubs, or other Insurance: Insurance Cards

Yes

No

Patient Name: __________________________________________________________________ Approved Discount: _____________________________________________________________ Approved by: __________________________________________________________________ Date Approved: _________________________________________________________________

Sliding fee application  
Sliding fee application  
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