PROCEDURE: These guidelines are to be followed in providing the Sliding Fee Discount Program.

1. Notification: The Promise Resource Center will notify clients of the Sliding Fee Discount Program by:

• An explanation of our Sliding Fee Discount Program and our application form are available on our website.
• The Promise Resource Center places notification of Sliding Fee Discount Program in the waiting area.

2. Requests for discount: Requests for discounted services may be made by clients, family members, social services staff, or others who are aware of existing financial hardship.

• Discounted services would apply effective the date of application approval going forward.
• Information and forms can be obtained from the Front Desk.

3. Administration: The Sliding Fee Discount Program procedure will be administered through the Finance and Administration Director or their designee. Information about the Sliding Fee Discount Program policy and procedure will be provided, and assistance offered after completion of the application. Dignity and confidentiality will be respected for all who seek and/or are provided charitable services.

4. Alternative payment sources: All alternative payment resources must be exhausted.

5. Application: The client/responsible party must complete the Sliding Fee Discount Program application in its entirety. By signing the Sliding Fee Discount Program application, persons authorize The Promise Resource Center 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.

• Initial application: If an application is unable to be processed due to the need for additional information, the applicant has two weeks from the date of notification to supply the necessary information without having the date on their application adjusted. If a client does not provide the requested information within the two-week time period, their application will be re-dated to the date on which they supply the requested information. Any accounts turned over for collection as a result of the client’s delay in providing information will not be considered for the Sliding Fee Discount Program.
• Renewal applications: A client who receives discounted services under this policy is required to submit an updated application every 12 months or if their financial situation changes. Failure to meet the annual financial information requirement may result in the client no longer being eligible for the Sliding Fee Discount Program. If a client is delinquent in meeting the updated annual application requirement, The Promise Resource Center will mail the client a notice they are being terminated from the Sliding Fee Discount Program unless they submit the required financial information within the time frame (10 business days) noted in the letter. If a client does not submit the renewal information, they are no longer eligible for the discounted services per the date in the notice letter.

6. Discounts: Discounts will be based on income and family size only. The Promise Resource Center defines a family as head of household, spouse, and dependent children.

7. Income includes: Earnings, unemployment compensation, workers’ compensation, Social Security, Supplemental Security Income, public assistance, veterans’ payments, survivor benefits, pension or retirement income, interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources. Noncash benefits (such as food stamps and housing subsidies) do not count.

8. Requirements: Applicants must provide the following: prior year W-2, two most recent bank statements, and two most recent pay stubs. Self-employed individuals will be required to submit details of the most recent three months of income and expenses for the business. Adequate information must be made available to determine eligibility for the program. Self-declaration of income may only be used in special circumstances. Specific examples include participants who are homeless. Clients who are unable to provide written verification must provide a signed statement of income, and why they are unable to provide independent verification. This statement will be reviewed and final determination as to the sliding fee percentage will be made. Self-declared clients will be responsible for 100% of their charges until management determines the appropriate category.

9. Updates: The sliding fee schedule will be updated during the first quarter of every calendar year with the latest federal poverty guidelines (aspe.hhs.gov/poverty).

10. Notice: The Sliding Fee Discount Program determination will be provided to the applicant(s) in writing, and will include the percentage of Sliding Fee Discount Program write off, or, if applicable, the reason for denial.

• The applicant has the option to reapply after the 12 months have expired or any time there has been a significant change in family income. When the applicant reapplies, the look back period will be the lesser of six months or the expiration of their last Sliding Fee Discount Program application.

11. Storage of information: Information related to Sliding Fee Discount Program decisions will be maintained and preserved in a centralized confidential file located in the Finance and Administration Director’s office, in an effort to preserve the dignity of those receiving discounted care.

12. Payment: Payments must be made at least 24 hours prior to the scheduled time of services.