Sliding Fee Discount Program

L.E.A.F. Therapy Services offers a Sliding Fee Discount Program (SFDP) to all individuals and families with annual incomes at or below 200% of the Federal Poverty Guidelines (FPG). The SFDP is offered for therapy services.

To determine eligibility for the SFDP, LEAF THERAPY SERVICES will need to ask you to bring in personal financial information. Any information we ask you to provide will be kept strictly confidential. None of your personal information can be released without your written consent. The information we are requesting will be used solely to determine your family size and income. Applications are effective for a one-year period. SFDP participants must complete an application annually. SFDP applications must be completed, signed and approved prior to services being provided. All participants are asked to notify LEAF THERAPY SERVICES of changes to family size and/or income as soon as possible after the change occurs.
Family Size is defined as the number of individuals receiving financial support from a head of household and includes the following:

1.	Client applying
2.	Individuals that can be claimed by the client on a Federal/State tax return
3.	Family members living with and financially supported by the client

Income is defined as earnings used to support an individual/household unit and is generally considered to be the adjusted gross income reported for income tax purposes.

Acceptable Forms of Proof of Income include the following:
1.	Most recent year’s Federal IRS Form 1040 (Adjusted Gross Income)
2.	Most recent pay stubs (2 consecutive)
3.	Letter from employer detailing gross wages, frequency of pay periods, and dates of employment
4.	Letter from Social Security, Veteran’s Affairs, or Employment Office that lists income

Self-Declaration of Income
Patients must bring required information for verification of family size and income at their first visit in order to qualify for the SFDP. However, if the patient does not have the information, they can be seen for 30 days at the slide level determined from a completed self-declaration form. Patients with no income may also complete a self-declaration form and be seen at slide level A for 30 days, at which time a third-party attestation form will need to be provided. Self- Declaration is only good for 30 days and one time in a 12 month period.

Third Party Insurance Coverage and Eligibility
Patients with third party insurance coverage are also eligible for the SFDP. Please provide your insurance card along with your SFDP application for a determination of your discount. LEAF THERAPY SERVICES attempts to assess all patients for SFDP eligibility; however, for those patients that choose not to provide the information required to determine family size and income, even after being informed that they may qualify for discounts, are viewed as declining eligibility for the SFDP. These patients will be considered ineligible for sliding fee discounts.
Sliding Fee Discount Schedules
Patients will be charged on the Sliding Fee Discount Schedule (SFDS) based on their family size and income and no other factors. Patients will also be charged according to the SFDS for the type of service provided. 

Payment Plans
Patients are expected to pay in full at the time of their visit. However, payment plans are available which allows patients to pay their outstanding balance over a period of time. Please speak with reception staff if you are interested in this program.

The Sliding Fee Discount Program is retroactive for 30 days. All applications must be completed in FULL. Applications cannot be accepted without proper proof of income. L.E.A.F. Therapy Services is pleased to help meet your healthcare needs. We invite you to share this Discount Program information with others. If you have questions about this program, please speak to the reception staff.

Countable income includes:
•	Taxable Wages
•	Self-employment
•	Retirement Benefits (including Social Security)
•	Unemployment
•	Alimony
•	Interest, dividends, rents, and royalties

Non-Countable income includes:
•	Child Support
•	Non-cash benefits such as food stamps and housing subsidies
•	Temporary assistance and other government cash assistance
•	Social Security Disability (SSD)
•	Supplemental Security Income (SSI)
•	Veteran’s benefits (VA Benefits) and disability (VA Disability)
•	Workers Compensation payments
•	Proceeds from life, accident, and health insurance
•	Scholarships, awards, and fellowship grants used for education
•	
Sliding Fee Discount Program Application
Date: 	
Applicant’s Full Name:				 Last	First	Middle

Applicant’s Address: 					 Street Address	City	State	Zip

County:		Date of Birth:	/	/	
Phone Number 	

Family Size:
Please list all members of your household whom you are financially responsible for, including yourself:

	Full Name of Household Member	Relationship	Date of Birth	
1				
2				
3				
4				
5				
6				
7				
8				

Income:
Please list all sources of income generated by anyone counted in family size, regardless of marital status. **Please see Countable Income and Non-Countable income on the previous page**

	Type of Income	Amount of Income	
1			
2			
3			
4			
5			
6			
7			
8			
	Total of all Rows		

If insured, please show reception a copy of your current insurance card.

Please initial understanding of the following items:
	I have read and understand the information contained in the “Sliding Fee Discount Program”
Initial Packet and agree to abide by these guidelines.
	I understand that the expiration date for this information will be on	per LEAF THERAPY SERVICES policy.
Initial

	I declare to information I have given is true and give L.E.A.F. Therapy Services 
Initial consent to investigate any information given in this application.

	 Based on the number of people in my household and the income information I provided, I
Initial understand (1) the fee for each therapy visit is $	_ (2) this fee is due at the time of service unless I have been approved for a payment plan.

Applicant’s Signature: 		Date: 	

Staff Signature: 		Date: 	

Federal Poverty Level: 	
Approved Discount Level: 	

Self-Declaration of Income

I, 	, declare that I have been receiving income in the amount of
$	per ☐Day ☐Week ☐Bi-weekly* ☐Semi-monthly* ☐Month

*Bi-Weekly pay is received every two weeks.
**Semi-Monthly pay is received twice a month (ex: Pay is received on the 1st and 15th of every month).

Amount paid per day: 		x260 = Annual income of $	  Amount paid Weekly: 	x52 = Annual income of $	 Amount paid Bi-Weekly: 	 x26 = Annual income of $	  Amount paid Semi-Monthly: 	 x24 = Annual income of $	  Amount paid Monthly: 	 x12  = Annual income of $		

*if unemployed*
I, 	, declare that I have no employment and do not have income of any kind.
I have no check stubs or other documentation to prove my earnings.

*I acknowledge this self-declaration may only be completed once in a rolling 12 month period and the SFPD will only apply for 30 days*

Patient Signature: 	

Date: 	

Office Use Only
I witness that this client has no documentation for proof of income:

Signature: 	

Date: 	

Third Party Attestation Form

I,	,
verify that, 	, is currently unemployed and has had no income this year. I help provide for his/her living expenses; however, I am not responsible for his/her debts.

Signature:	Date:

Relationship:

L.E.A.F. Therapy Services LLC

L.E.A.F. Therapy Services Sliding Fee Discount Schedule Effective February 1/1/ 2025

Office Fee Per Visit

Sliding Fee Discount Program Eligibility is based solely on Family Size and Income

Office Fee Per Visit	
Assessment	$95	$100	$105	$110	Full Fee	
Therapy	$65	$75	$85	$95	Full Fee	
Federal Poverty Guidelines (2025)	
Family Size	Level A
(0-100% PFG)	Level B (101-133% PFG)	Level C (134-166% FPG)	Level D (167-200% FPG)	Level E (Above 200% FPG)	
1	$0	-	$ 15,650	$ 15,651	- $ 20,815	$ 20,816	-	$ 25,979	$ 25,980	-	$ 31,300	$ 31,301 and	Above	
2	$0	-	$ 21,150	$ 21,151	- $ 28,130	$ 28,131	-	$ 35,109	$ 35,110	-	$ 42,300	$ 42,301 and	Above	
3	$0	-	$ 26,650	$ 26,651	- $ 35,445	$ 35,446	-	$ 44,239	$ 44,240	-	$ 53,300	$ 53,301 and	Above	
4	$0	-	$ 32,150	$ 32,151	- $ 42,760	$ 42,761	-	$ 53,369	$ 53,370	-	$ 64,300	$ 64,301 and	Above	
5	$0	-	$ 37,650	$ 37,651	- $ 50,075	$ 50,076	-	$ 62,499	$ 62,500	-	$ 75,300	$ 75,301 and	Above	
6	$0	-	$ 43,150	$ 43,151	- $ 57,390	$ 57,391	-	$ 71,629	$ 71,630	-	$ 86,300	$ 86,301 and	Above	
7	$0	-	$ 48,650	$ 48,651	- $ 64,705	$ 64,706	-	$ 80,759	$ 80,760	-	$ 97,300	$ 97,301 and	Above	
8	$0	-	$ 54,150	$ 54,151	- $ 72,020	$ 72,021	-	$ 89,889	$ 89,890	-	$ 108,300	$ 108,301 and	Above	
9 or more	Add $5,500 for each additional member	Add $7,315 for each additional member	Add $9,130 for each additional member	Add $11,000 for each additional member