Shelia Clark, Ph.D. Discount Fee Policy

It is the policy of Shelia Clark, Ph.D. to provide psychological services regardless of the patient’s ability to pay. Discounts are offered based upon household income and size. A sliding fee schedule is used to calculate the basic discount and is updated each year using the federal poverty guidelines. Once approved, the discount will be honored for six months, after which the patient must reapply.

Discount Application Process

A completed application including required documentation of the home address, household income, and insurance coverage must be on file and approved by the business office before a discount will be granted. If the applicant appears to be eligible for Medicaid, a written denial of coverage by Medicaid may also be required.

Adolescent patients seeking confidential care are exempt from the application process, and services are provided at the nominal rate.

Please complete the following information and return to your therapist to determine if you or members of your family are eligible for a discount.

The discount will apply to all services received at this clinic, but not those services which are purchased from outside. In the hope that your financial situation improves, discounts apply only to current, not future services. This form must be completed for each visit.

Note: Include income from all sources including gross wages, tips, social security, disability, pensions, annuities, veterans payments, net business or self employment, alimony, child support, military, unemployment, and public aid.

We will need proof of your income, either your current IRS 1040 Tax Return or your annual benefit notice from the Social Security Administration. Family Assistance Plan

NOTE: Medicare, Medicaid and Victims of Crime recipients are not eligible for the Sliding Fee Scale Program.

First Name of Head of Household: ______

Last Name:______

Social Security No.: ______

Residence Address:______

City:______

State: ______Zip: ______

Mailing Address (if different): ______

City:______

State: ______Zip: ______

Day time Telephone: ______

Night Telephone: ______

Cell: ______

Place of Employment (Name): ______

Address: ______

Telephone Number: ______

Insurance Carrier Name: ______

Address: ______

Policy #: ______Group #: ______

Benefits Tel #: ______

Other pertinent billing info: ______

List self & spouse and dependents under age 18

Name / Date of Birth
Self
Spouse
Dependent
Dependent
Dependent
Dependent

Annual Household Income

Source / Self / Spouse / Other / Total
Gross wages, salaries, tips, etc.
(give employment information on family members)
Social security, pension, annuity, and veteran’s benefits
Alimony, child support, military family allotments
Income from business self employment, and dependents
Rent, interest, dividend, and other income
Cash Welfare Payments:
Disability (also please describe disability):
Unemployment:
Interest income:
Any other income:
Total Income
Verification Checklist (attach copies) / Yes / No
Identification/Address: Driver’s license, birth certificate, employment ID, social security card or other ____Yes ____No
Income: Prior year tax return, three most recent pay stubs, or other ___Yes ___No
Insurance: Insurance card(s) ____Yes ____No
Medicaid: Application made or evidence of rejection. ___Yes ____No

Are there any special needs and circumstances which would help accurately reflect your current financial situation (i.e. other medical bills, etc.)? ______

______

I certify that the information shown above is true and correct and understand verification is required for approval. I hereby authorize Shelia Clark, Ph.D. to verify any of the above data and release the above information to referring/mutual providers of care.

______

Name (Print) of Head of Household & Signature & Date

Name & Signature of other individuals submitting any of above data.

______

Office Use Only

Pay class approved: ______

Effective date: ______

Approved by: ______

Expiration date: ______