CONFIDENTIAL

FEE REDUCTION/FEE WAIVER APPLICATION

Your CHSP fee may be reduced in part or in full if you have other high costs that impact on your ability to contribute.

To determine whether you are eligible to pay a reduced fee, or have your fee waived for a period of time, your CHSP provider needs some information about your circumstances. The information can be used to adjust or waive the fee you need to pay. Any information you provide is treated as private and confidential. You will be provided with a copy of this form for your records.

CLIENT DETAILS

Surname or Family Name______

Given Names ______

Home Address______

______Postcode ______

Telephone

Age Group: 0-15 years : Complete this form based on parental income

 16yrs or over: Complete this form based on personal income
Please indicate, in the categories below, the costs you incur because of your current circumstances, or the circumstances of your family member (if you are filling this out on behalf of someone else).

Before recording an amount you should deduct from it any reimbursement you have received from another source, for example, a refund from a private health insurer.

**Income Source / Weekly Income / Comments
Aged Pension/DVA/Other
(only include your share of pension if you live with a spouse
Superannuation/investments
Other income
Total weekly income
**Weekly Expenses
Rent or mortgage
Council Rates
Electricity or Gas
Telephone
Water Rates
Food
Transport
Health Care
Chemist/medications
Equipment Hire
Other costs (please list)
Total weekly expenditure
Money remaining each week
(income minus expenditure)
Any other comments:

** Only include your share of your income or expenses. If you live with a spouse/carer reduce the income and expenditure by 50%

Your service provider will discuss a suitable fee with you.Your Service Provider will use the following process to determine whether to reduce or waive your fee.

Calculating Fee Waiver

As a guide: If your total available left over income will create hardship then you may be entitled to a reduced fee or a waiver of the fee according to your income level (i.e., Level 3, Level 2 or Level 1).

Calculating Fee Reduction

Level 3 client / Reduce fee rate to level 2
Level 2 client / Reduce fee rate to level 1
Level 1 client / How much can client afford to contribute

Review Fee Reduction or Fee Waiver

Is the current financial situation / Short-term
(please tick) / Long-term
(please tick)
Review Date / / / / Not Applicable

To the best of my knowledge, this is a true and accurate statement. I agree that the informationI have provided can be used to set fees for the CHSP services I receive.

Signed ______Date ______

Printed Name ______

If you completed and signed this form on behalf of the client, please provide your name and address.

Surname or Family Name ______

Given Names ______

Address ______

______Postcode ______

Telephone ______

What is your relationship to the client? ______

Thank you for completing this form. Please sign the form where indicated above and return this form to CHSP, Adelaide City Council, GPO Box 2252, Adelaide 5001

ACC2015/126343