Sliding Fee Discount Program

Fill out the following form to see if you qualify for our sliding fee discount program based on family size and income.

No one will be denied services due to their inability to pay.

Slicing Fee Discount Program Application

Name

First Name

Last Name

Address

City

State

Zip Code

Home Phone

Other Phone

Income Verification

Income Information: Please complete for all household members who are employed. Proof of income (income tax return and/or last two paystubs MUST be provided to Sandia Therapy and Wellness Center. Otherwise, services will be rendered at the customary price.

Company Name

Income (before taxes)

Paid how often?

Weekly, every two weeks, twice a month

Other sources of income and how much you are paid

Household Information: List ALL individuals in household including children and head of household

Extenuating Financial Factors

Electronic Signature

By placing my name below, I agree to provice Sandia Therapy and Wellness Center with proof of income for the purpose of calculating my discount. I will be asked to reapply for the program on an annual basis. I certify that the income and family size information is true and correct.

Please identify how many family members are in your household, including yourself.

Date of submission

YYYY

Supporting Documentation

I agree to supply proof of income in the form of tax information, pay stubs, or other acceptable documentation to Sandia Therapy and Wellness Center to allow this discount to be reviewed. This documentation can be mailed or hand-delivered to Sandia Therapy and Wellness Center at 6612 Gulton Ct NE Ste B Albuquerque, NM 87109

I agree