SORS Services

SORS Services

Copay and Deductible Assistance
Your provider at Ravenwood Health has identified that you may be eligible for additional services as well as help in covering copays and deductibles that are not paid by your insurance. In order to be eligible for these items we need this short application completed.
Client's Full Name *

First Name Last Name
Client's Date Of Birth *

Month Day Year
Date
Annual Household Income (How much money does the family make in a year?) *
How many people are in your household? *
Please explain how having to pay copays and deductibles for services would make it difficult for your family. *
The funding for which you are applying will help to cover your costs for the MAT program, Peer Support, and other services based on certain diagnoses (Opioid and Stimulant use). The funding will not cover any treatment outside of these areas including doctor visits for anxiety, depression.... If you have any questions about what is or is not covered please talk with your treatment provider. Thank you.
By signing below I attest that the information provided above is accurate. *

Clear
Signature Date *

Month Day Year
Date
Should be Empty: