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InnerSourced services are open to all persons regardless of race, ethnicity, age, sex, sexual orientation, gender and/or gender identity, ability, national origin, and any other characteristic protected by federal, state or local laws.

©2019 by InnerSourced Solutions, LLC. 

SLIDING FEE SCALE

Frequently Asked Questions

What is the Sliding Fee Scale?

InnerSourced Solutions, LLC offers affordable counseling / therapy and other programs and services through the use of the sliding fee discount program to uninsured and under insured qualified individuals and families.  Eligibility is based on family size and family income.  The Sliding Fee Discount Program Scale is based on the annual definition of federal poverty provided by the Department of Health and Human Services, and is divided into four categories:  A, B, C, D, and E.

This program works in part, in accordance with the Federal Poverty Guidelines, which can be found here.

 

Who can apply for the Sliding Fee Scale?
All  clients are eligible to apply for the Sliding Fee Discount.  Even patients that have insurance may apply to help lower the cost of non-covered services.

How is eligibility for the Sliding Fee Scale determined?
Eligibility is determined on the household size, annual gross income (net income for self-employment) for the household, completed application, and proof of income.

How do I get an application for this program?
Ask for a Sliding Fee Scale packet at our front desk staff or download below. 

What type of documents do I need to bring to apply for Sliding Fee Scale?
You will need to bring in proof of income for all the household members over age 18 and a completed Sliding Fee Application.

 

 

What can be used as Proof of Income?
 Accepted documents for proof of income:

  •  Current Federal Income Tax (1040-1040 EZ Form, no W2s)

  •  Paystubs for recent month 

  •  Current bank statement showing direct deposit (SS, SSI, SSD, Child support) 

  •  Social Security/Disability Letter

  •  Unemployment Benefit Letter (no bank statements)

  •  Letter of Support

  •  Court order for alimony or child support or printout for child support payments 

  •  Pension Benefit Letter

  •  Wages (4 pay stubs if paid weekly, 2 pay stubs if paid bi-weekly)

 

Who is considered a “household member”?
Household members are related by blood, marriage or adoption, and financially responsible to each other. Roommates do not qualify as a ‘Household member’. 

When is my Sliding Fee Scale effective?
The sliding fee scale discount, if you qualify, will backdate 14 days from the day which you are given the application.

When does my Sliding Fee Scale expire?
The Sliding Fee Scale discount will expire at the end of month, 1 year from approval date.

You must re-apply prior to the expiration date in order to continue being covered under the Sliding Fee Scale Program. Failure to do so may result in the patient being responsible for the full amount of any charges incurred during the lapse.

How often do I need to apply for this program?
You must apply every year. You may re-apply up to four times a year if there is a change in your current household size or income.

I do not want to provide my financial information. Am I still eligible for the Sliding Fee Scale?
Eligibility for the Sliding Fee Scale is based on your income and household size. If you choose not to provide InnerSourced Solutions with this information you will be responsible for the total charges for services received.

What services does the Sliding Fee Scale cover?
Behavioral Health visits.

How much will I pay if I am approved for the program?
The charge for your visit depends on your income, household size, and the type of service you received. When you are approved for the Sliding Fee Scale you will receive a card that details your financial responsibility for services received. Payments are due at the time of service. If you have private insurance, your normal co-pays still applies.

 

 

 

 

Who should I contact if I have more questions?
Your Program Director or Your Therapist can help you. 

 

Click on the links below to view and/or print. 
Sliding Fee Scale Application

Statement of Support

Employment Verification