Financial hardship
If paying for care is a real difficulty, tell us.
Money should not be the reason you stop treatment. A financial hardship request is reviewed privately by our billing team, and the outcome never affects the care you receive.
Before you start
What the form asks for.
Requests are considered against the federal poverty guidelines, so the form needs a picture of your household and its income. Gathering these first means you can finish in one sitting.
- 1
Household size and income
How many people live in your household, including you, and the household's total income before taxes. The form also asks what kind of income it is — employment, retirement, Social Security, disability, unemployment or other.
- 2
Something that verifies it
Recent pay stubs, your last tax return, or a government benefit statement. You attach these directly to the form; photos from your phone are fine as long as they are readable.
- 3
Your circumstances, in your own words
A short explanation of what has changed — a job loss, an illness, a caring responsibility. It does not need to be long. It needs to be true.
- 4
A signature
The form ends with a declaration that what you have told us is accurate and complete. You sign it on screen.
Request form
Submit your request.
The form is hosted on a HIPAA-compliant service and your submission is encrypted. It goes to the billing team, and only to them.
FAQ
Common questions
- Will asking for financial help affect my treatment?
- No. A hardship request is reviewed privately by our billing team, and the outcome never affects the care you receive or the way you are treated at the clinic.
- Who sees what I submit?
- The form is hosted on a HIPAA-compliant service and your submission is encrypted. It is reviewed by the billing staff responsible for financial assistance, not by the clinic front desk or your therapist.
- What does “based on the federal poverty laws” mean?
- The form states that requests are considered against the federal poverty guidelines referenced in Internal Revenue Code Section 501(r). In practice that means household size and income are compared with the federal poverty level for a household of that size.
- What if I cannot attach the documents right now?
- Submit the form with what you have and note in the circumstances box what is missing and when you can provide it. The billing team can tell you how to send the rest.
- I just have a question about a statement. Is this the right place?
- Probably not. A billing question — a charge you do not recognize, an insurance payment that has not posted — is quicker to resolve by calling the main office. This form is for when the amount itself is more than you can pay.