Portneuf Valley Family Center Inc.
Sliding FeeScale Application
Portneuf Valley Family Center Inc. recognizes that some consumers may not have the ability to pay full fees for mental health services and may need other fee scale options for payment. Please complete the following information.
The following information will be used to determine the amount of payment required.
- Total monthly income in the household as evidenced by the 2 most recent pay check stubs.
- Number of individuals in the household.
- Copy of denial letter from Medicaid or proof of any third party payer resource denial.
Complete the following informationto determine fee schedule:
A.) Name of individual applying for sliding fee scale:______
(please print name)
B). Total Household Monthly Income:______(please attach the 2 most recent paycheck stubs)
C). List all individuals living in the home:
Name:______Age:______
Name:______Age:______
Name:______Age:______
Name:______Age:______
Name:______Age:______
Name:______Age:______
Name:______Age:______
Name:______Age:______
Once this application has been submitted, we will review and make a determination based on the SLIDING FEE SCALE that is used by the State of Idaho, Department of Health and Welfare. This determination is a percentage of your reported income or a minimum of $30.00 per psychotherapy session, $50.00 for a medication management session, and $20.00 per hour of a CBRS/TCM service. We will notify you within five (5) days of the amount that will be charged based onthe application including the amount that will be due at the time of service. A copy of the Sliding Fee Scale is available upon request.
If it is determined that you have no resources or means to pay we do offer Pro Bono Services as availability warrants. For those individuals who qualify at 100% below the poverty level and have no ability to pay – pro bono services are available.
By signing below I acknowledge that all of the information on this form is accurate and valid at the time of application. I understand that I am fully responsible to pay for all services rendered on my(or my child’s) behalf at the agreed upon or determined rates. I further understand that no one receiving treatment from Portneuf Valley Family Center, Inc. will be denied access to services due to inability to pay. We offer this discounted sliding fee schedule for all those who qualify.
Consumer/Guardian Signature:______Date:______
*For Office Use Only*
Total Household Income: Total Individuals living in the home:
Service Payment Due: Code Billed:______Payment Due:______Code Billed:______Payment Due:______
Code Billed:______Payment Due:______Code Billed:______Payment Due:______
______
Staff Initials Code Billed:______Payment Due:______Code Billed:______Payment Due:______
06/04/16 Revised. Sliding Fee Scale Application. Property of Portneuf Valley Family Center, Inc.©. Unauthorized Copying, Changing, or Distribution without permission is strictly prohibited. Phone: (208) 233-7832 Fax: (208) 233-7835