Sliding Fee Discount Program
Reduced-cost care for eligible patients, based on household income and family size. No patient is denied care for inability to pay.
See the Sliding Fee Scale (PDF) for current tier guidelines.
Please contact our office — one of our case managers will assist you.
Call us
Speak to our front office and we'll help you start the application by phone.
1-833-906-4148Email us
Send a short note describing your situation and we'll follow up.
hello@elevatementalwellness.netResponse within 1 business day
Fill out the application
Submit the short, HIPAA-secure application directly on this page.
Jump to the formResponse within 1 business day
Apply for the Sliding Fee Discount Program
The form below is hosted by Microsoft Forms and submits securely. Responses are sent directly to our billing team — we'll get back to you within 1 business day.
Prefer to open it in a new window? Open the application.
Questions about the program.
Do I have to apply every visit?
No. The discount tier you qualify for applies to subsequent visits. We may ask you to re-verify income and household size annually or if your situation changes.
What income documentation will I need?
Typically recent pay stubs, a tax return, W-2, Social Security statement, or similar. If you have no income, a brief statement explaining your situation is fine. Our team will guide you through what's needed.
Is my information confidential?
Yes. All information submitted is treated as protected health information under HIPAA and used only to determine eligibility for the discount program.
What if my insurance covers part of a service?
The Sliding Fee Discount Program does not apply to services that your insurance is paying for. Copays and deductibles remain the patient's responsibility under the terms of the plan.
Questions? Call 1-833-906-4148 or email hello@elevatementalwellness.net.