The center for therapeutic services and psychodiagnostics has adopted the following policies for charges for health care services



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THE CENTER FOR THERAPEUTIC SERVICES AND PSYCHODIAGNOSTICS HAS ADOPTED THE FOLLOWING POLICIES FOR CHARGES FOR HEALTH CARE SERVICES

We will charge persons receiving health services at the usual and customary rate prevailing in this area. Health services will be provided at a reduced charge to persons unable to pay for services. In addition, persons will be charged for services to the extent that payment will be made by a third party authorized or under legal obligation to pay the charges. We will not discriminate against any person receiving health services because of their inability to pay for services.




CENTER FOR THERAPEUTIC SERVICES AND PSYCHODIAGNOSTICS

APPLICATION FOR REDUCED FEE

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



NAME OF HEAD OF HOUSEHOLD

PLACE OF EMPLOYMENT

STREET

CITY

STATE

ZIP

PHONE #

HEALTH INSURANCE PLAN

POLICY #

Annual Income Amount:
$______, ________.00




SOCIAL SECURITY NUMBER:
_______-_____-_______

_______-_____-_______

Number of Individuals in the Household

RELATIONSHIP

NAME

DATE OF BIRTH

INCOME

Self










Spouse/Partner










Dependent










Dependent










Dependent










Dependent










Dependent










Dependent













SOURCE OF INCOME

SELF

SPOUSE

OTHER

TOTAL

Alimony, child support, military family allotments














Income from employment, business self-employment, and dependents














Rent, interest, dividend, pension, social security, annuity, veteran’s benefits














TOTAL INCOME













I certify that the family size and income information shown above is correct. Copies of tax returns, pay stubs, and other information verifying income will be required before a discount is approved.


Name (Printed) _________________ Date: _______________________

Signature ____________________________________________________



VERIFICATION CHECKLIST (attach copies)

FORM

YES

NO

Identification/Address: Driver’s license, birth certification, social security card, other







Income: tax returns, three most recent pay stubs, or other







Copy of Insurance Card/TYPE:







FOR OFFICE USE ONLY:

CLIENT NAME: _______________________ APPROVED BY: _______________________ DATE: _______________________

6 MONTH DISCOUNT AMOUNT:

$_______________________



CFTSAP SLIDING FEE SCALE APPLICATION Page




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