Discount Fee Application

Discount Fee Application

The Center offers a Discount Fee Program that reduces the cost of medical, dental, behavioral health, and substance use treatment.
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
SSN
If you do not have a SSN, enter 777-77-7777
Street Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary phone (the phone number you use most) *
Please enter a valid phone number.
Phone type

HomeCellularWork
Email
example@example.com
How many people are in your family, including yourself?*
Your Income:*
Other members of your family, if applicable
Please provide proof of all income received.

Two paycheck stubs, Retirement, Social Security, Award Letters, Disability, Worker's Compensation, Unemployment, etc.

If you do not have a source of income, please contact our Intake Department for further assistance.

Please note: without proof of income, we cannot process your application for discounted fees.
File Upload

Cancelof
The information provided is, to the best of my knowledge and belief, accurate and true. I authorize the release of all information which the Center may need to determine whether I qualify for financial assistance through their Discount Fee Program. I understand that eligibility in the program expires 12 months from my signature date below and that I must reapply after the eligibility period expires. I understand that I must inform the Center of any changes in my household (income and size) during this 12-month period.
Signature of patient (or parent/guardian if patient is under 18)*

Clear
Date

MonthDayYear
Date
Should be Empty: