Complete Wellness

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 Discount.

 1.

 2.

 3.

Download the Sliding Scale Fee Application. You can go directly to the application
document by selecting this button:  

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:

  • Paycheck stub (most recent)

  • W-2 form

  • Last Income Tax Return

  • Written statement from employer

  • Unemployment check stub

  • 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:

Applications must be mailed to:

Complete Wellness

Attention: SSF

10 West Madison Street #11

Baltimore, MD  21201

All Steps Must Be Completed for Consideration

 

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. 

 

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, Inc. access in confirming 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.

Visit

10 West Madison Street #11

Baltimore, MD 21201 

Call

T: 443-438-7863

F: 443-957-9485 

Visit

10 East Baltimore Street Suite 1400

Baltimore, MD 21202 

© 2015-2019 by

Complete Wellness, Inc

All rights reserved

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