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  • Sliding Fee Scale Application

    Sliding Fee Scale Application

    *THIS FORM TO BE COMPLETED AFTER INITIAL REGISTRATION FORMS*
  • For your assistance, we have a sliding fee discount program. In order for us to determine if you qualify, please provide us with the following information:

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  • If Reporting No Income

  • *****Self-declared income will apply sliding fee discount for 30 days only. To be eligible for future discounted services financial documentation will be required.

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