Sliding Fee Scale. The Network Service Provider shall ensure compliance with the provisions of Rule 65E- 14.018, F.A.C. A copy of the Network Service Provider’s sliding fee scale that reflects the uniform schedule of discounts referenced in Rule 65E-14.018, F.A.C., shall be kept in the Network Service Provider’s contract file. The Network Service Provider shall submit to the Network Manager, within 15 days of the execution of this contract, a copy of the Network Service Provider’s sliding fee scale.
Sliding Fee Scale. If you are uninsured or choose not to use your insurance. You must complete the sliding fee scale fee on pg. 4 and your ongoing rate will be determined based on your total family income. The intake appointment for all sliding fee clients is $75. Please initial one of these three financial arrangements), indicating the appropriate option for you. INSURANCE (NON-PROVIDER) If we are not providers in your insurance plan (“out-of-network”). INSURANCE (PROVIDER) If we are providers in your insurance plan (“in-network”). SLIDING FEE SCALE For those who are paying out-of-pocket. Cost per session will be determined by your family’s income and insurance will not be filed. *Complete form on pg. 4*. My signature below indicates that I have read and understand this fee policy. I agree to take responsibility for fees in accordance with my selection of options in Section 1. Printed Name Signature (of primary insured, if using insurance) Date Sliding Fee Scale Form ** This form is ONLY to be completed by clients choosing NOT to file insurance*** Household Income: Information used solely to determine weekly fee for treatment. Please complete the form below honestly and to the best of your ability. Xx. Xxxxx reserves the right to request financial forms (e.g., W-2, paystubs, etc.) to verify the information, if needed. Please include income for all individuals in the household and income from other sources, including: gross wages, tips, social security, public aid, disability, pensions, net business or self employment, alimony, child support, unemployment, and other. Name Amount Frequency (Circle one) Employer: Occupation/Trade: You $ Weekly Monthly Yearly Spouse $ Weekly Monthly Yearly Children $ Weekly Monthly Yearly Other $ Weekly Monthly Yearly TOTAL $ Weekly Monthly Yearly Total # of Household members: Based on the gross household income and number of household members, we agree that the regular session fee for therapy is:
Sliding Fee Scale. CONTRACTOR shall establish a sliding fee scale for the purposes of billing indigent clients who are not eligible for Medi-Cal in accordance with their income. This sliding fee scale shall apply to any drug or alcohol prevention or treatment services provided to indigent clients, and shall be established in accordance with California Health and Safety Code Sections 11758.421 and 11758.425. CONTRACTOR shall conspicuously post one or more notices in the public area of each CONTRACTOR facility advising indigent clients of the availability of such discounted services. CONTRACTOR shall submit documentation of its sliding fee scale to COUNTY at contract commencement and whenever it is updated thereafter, that is sufficient to meet State DMC audit requirements.
Sliding Fee Scale. If any charges are imposed upon a client for the provision of RH services assisted by the State under this Program Element, such charges: (1) will be pursuant to an OHA- approved sliding fee schedule of charges, (2) will not be imposed with respect to services provided to low-income clients, and (3) will be adjusted to reflect the income, resources, and family size of the client provided the services, in accordance with 42 USC §701-709. Xxxxxxxx 00 XXX 59.5(a)(7) and (8)
Sliding Fee Scale. The managing entity shall require the network providers to comply with the provisions of Rule 65E-14.018, F.A.C. A copy of the subcontractors sliding fee scales that reflects the uniform schedule of discounts referenced in Rule 65E-14.018(4), F.A.C. shall be furnished by the managing entity to the department’s contract manager within thirty (30) days of contract execution. The managing entity shall submit to the contract manager, within thirty
Sliding Fee Scale. If any charges are imposed upon a client for the provision of health services assisted by the State under this Program Element, such charges: (1) will be pursuant to a public sliding fee schedule of charges, (2) will not be imposed with respect to services provided to low-income mothers and children, and (3) will be adjusted to reflect the income, resources, and family size of the client provided the services, in accordance with Title V, Section 505 [42 USC 705 (5) (D)].
