Instructions

Patient Grant Applications

• All grant applicants must complete the Financial affadavit form and the Grant Intake Forms
• All questions must be completed by clinician at the time of the interview.
• Forms Reviewed by Tim for Financial and Steve for Clinical
• Clinician will be informed within 48 business hours of disposition

Self Pay Clients

Self pay clients who are unable to make payment at time of service must complete Financial Affadavit Form and a payment schedule will be created to fit the patients immediate finncial status. Patients unable to make payment will be required to sign a legally binding agreement – Self-Pay Patient Responsibility Agreement.