Sliding Fee Application

Sliding Fee Application
This form is being completed for*

An existing clientA new client
Please indicate the name of the provider that you are working with or would like to work with: *
Client Information*

First NameLast Name
Client's Date of Birth*
Select which best describes your situation*

I am not insured and would like to pay out of pocketI am insured but the provider I want to see is out of network with my insurance and I WILL NOT request a Superbill and will NOT use my out of network benefits.
If your insurance company is in-network with The Luminous Mind but you are choosing not to use it, we are UNABLE to offer reducted rates. You are free to utilize our services without billing your insurance, but we will not be able to apply any discount.

If you are insured with an out-of-network insurance company, obtaining any reduced rates through this process will result in our inablility to issue a superbill and subsequently your inability to utilize any potential out-of-network benefits.
Income Information
Annual Income for Client's household in 2023*
Number of Dependents claimed on 2023 taxes*

01-23-45-67-89 or more
Please upload a copy of your 2023 tax return

Cancelof
I am aware that:
- I am responsible for providing accurate information regarding my income and that I am able to submit tax returns and/or pay stubs to verify this
- I am responsible for completing a Payment Authorization Form.
- I am responsible for updating the Pyamnet Authorization Form as necessary.
- I will not be able to retroactively use my insurance after opting out of using it
- In the case of a no-show or late cancellation, I am responsible for paying the no-show fee.
This form is being completed as undersigned client (or their legal guardian in case of minor) has elected to private pay for mental health services to be rendered at The Luminous Mind. I understand that upon submitting this information I will be contacted regarding cost of services based on information that I have provided. I acknowledge that if information submitted by me is found to be false, I will be liable for the full cost of services. *

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Sliding Fee Application

Income Information