It is the goal of The Resilience Group to make services available regardless of a patient’s ability to pay. A sliding scale, or reduced rate, is offered based on family size and annual income. Please complete the following information and return to us to determine if you or members of your family are eligible for a reduced rate. This form must be completed every 12 months or if your financial situation changes.
Gross wages, salaries, tips, etc:Self: Spouse: Other: Total:
Income from business, self-employment, and dependents:Self: Spouse: Other: Total:
Unemployment compensation, workers' compensation, Social Security, Supplemental Security Income, public assistance, veterans' payments, survivor benefits, pension or retirement income:Self: Spouse: Other: Total:
Interest, dividends, rents, royalties, income from estates, trusts, educational assistance,alimony, child support, assistance from outside the household, and other miscellaneous sources:Self: Spouse: Other: Total:
NOTE: Additional documents required include either your most recent year’s tax return or the most recent four (4) pay stubs to verify income OR a GA DOL-4 or the most recent remittance statement from unemployment. We also need a copy of your driver’s license to verify identity. Copies of tax returns, pay stubs, or other information verifying income and identity ARE required before a reduced rate is approved.
