Sliding Scale Fee Discount Program
From the beginning, the mission of Complete Wellness has been to provide the highest quality services to those struggling with issues related to mental illness regardless of ability to pay. To provide some organization and structure to this aspect of our mission, we have adopted the Sliding Scale Fee Discount Program.
The Sliding Scale Fee Discount Program was created to ensure that comprehensive mental health services are available and accessible to uninsured and underinsursed patients by providing an affordable fee structure that is in accordance with federal regulations.
Eligibility for the Sliding Scale Fee Discount
Any individual may apply for the Sliding Scale Fee Discount; however, eligibility in the program is based on the household annual income and family size. Only individuals living in households with income below 450% of the Federal Poverty Level may qualify for a Sliding Scale Fee discount.
The Sliding Scale Fee Discount is only available to individuals and families who are uninsured or under-insured.
As part of the intake process, if an individual is uninsured, the individual will be informed of the availability of the Sliding Scale Fee Discount and explain the paperwork needed to complete the application.
Applying for the Sliding Scale Fee Discount
There are 3 major steps in applying for the Sliding Scale Fee Disc
Download the Sliding Scale Fee Application. You can go directly to the application document by selecting this button:
All Steps Must Be Completed for Consideration
1.
Individuals interested in applying for the discount must provide evidence of their financial status. Applicants have 2 weeks to provide information on income status. After that time, the application is considered denied. A new application may be resubmitted once the income verification materials are provided.
Income status can be verified by 2 of the following forms of written verification of household income and size:
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Paycheck stub (most recent)
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W-2 form
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Last Income Tax Return
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Written statement from employer
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Unemployment check stub
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Social security check stub
In some cases, an individual is unable to provide proof of income. The Self-Declaration of Income must be completed as an alternative. For information on the Self-Declaration form, please select this button:
2.
3.
Applications must be emailed to Office@CompleteW.com or mailed through the postal system to:
Complete Wellness
Attention: SSF
10 West Madison Street #11
Baltimore, MD 21201
Sliding Scale Fee Discount Application
To apply for the Sliding Scale Fee Discount, you must first complete the application. The application is available at the Complete Wellness offices or you may download the application by selecting this button.
The application must be completed in its entirety in order to be consider for eligibility.
Self-Declaration of Income Form
Complete Wellness recognizes that some forms may not be available that could be used to verify income status. The Self-Declaration of Income Form can be used as a substitute as long as a reason for the substitute is provided. You may download the Self-Declaration of Inform Form by selection this button.
Falsifying information on this form will invalidate your application.
Submit Sliding Scale Fee Application and Self Declaration of Income Form to Office@completew.com
OR
Send all required documents to Complete Wellness, Attention: SSF, 10 West Madison Street #11, Baltimore, MD 21201
Application Review Process
Once the application is reviewed, you will be contacted by Complete Wellness in writing
of the yearly discount granted and the expected amount you will be required to pay for
your treatment.
If the application is denied, the reason for the denial will be included in the written
decision regarding the application.
Once notified of the decision regarding the Sliding Scale Fee Discount Application, you must immediately let Complete Wellness know if you intend to continue your treatment and how you intend to pay the fees for services.
If you do not contact Complete Wellness within 2 weeks of notification of a Sliding Scale Fee Discount, the discount will be declined and you may reapply for the Sliding Scale Fee Discount in 90 days.
The Application Review Process is approximately
1 month from receiving completed application.
The Fine Print
The Sliding Scale Fee Discount may be applied to services received for psychotherapy and medication management. Psychological testing, group psychotherapy, and acupuncture are not eligible services under the Sliding Scale Fee Discount Program.
By signing the application, persons authorize Complete Wellness, Incorporated the necessary access to confirm income as disclosed on the application form.
Providing false information on a Sliding Fee Discount Program Application will result in all Sliding Fee Discount Program discounts being revoked and the full balance of the account(s) restored and payable immediately.
Sliding Fee Discount Program applications cover outstanding patient balances for six months prior to application date and any balances incurred within 12 months after the approved date, unless their financial situation changes significantly.
The applicant has the option to reapply after 12 months have expired or anytime there has been a significant change in family income.