Financial Assessment Application (For determination of sliding fee eligibility) Please submit this application with copies of all supporting documentation as requested. The application must be filled out in its entirety and submitted. If you are AHCCCS-eligible or believe you might be AHCCCS-eligible, STOP. Do not fill out form . Please contact the Financial Eligibility team at 602-761-4930 for further instructions Incomplete applications or those missing documentation will not be processed for review. Please include the following documents, if applicable: If unemployed: Include Three (3) most recent payroll stubs or Prior Year Federal Income Tax Return. Letter of Unemployment Benefits eligibility, stating monthly $ amount; or unemployment denial letter, if applicable. If currently employed: Include 3 most recent payroll stubs. Documentation supporting additional sources of income to include: Social Security, Medicaid, SNAP (former food stamps) pension, annuity, veterans’ benefits, alimony, child support, military benefits, businesses, rent, interest, dividends, and any other income). Documentation should show weekly or monthly benefits. ****** If you are submitting documentation that contain social security numbers, please redact or black-out those social security numbers. ******* Please complete and return this application, along with required supporting documents, within 7 business days of receipt. Incomplete applications or applications submitted after 7 business days will not be processed and you will not be eligible for a discount. Applications can be submitted the following ways: Using this form In Person Email: DFA@SAGEcounseling.net Fax: 480-649-3358 Mail: SAGE Counseling – Administration Office 1830 S. Alma School Rd. Suite 104 Mesa AZ 85210 If you are interrupted while completing this form, there is a Save and Continue Later link at the bottom of the form that can be used. Make sure you email the generated link to yourself so that you don’t have to restart the form from the beginning.Attach files here: Drop files here or Select files Max. file size: 128 MB. Name:* First Last Date of Birth:* MM slash DD slash YYYY Phone Number where you can be reached:*Email:*A copy of your submission will be sent to this address Section A: AddressPhysical Address (Cannot be a PO Box):*(All applicants must provide a physical address or an address for a shelter) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I am homeless residing in a shelter:* Yes No If you checked the box indicating that you reside in a shelter please provide the name, address and contact number for the shelter. You will also be required to complete the attached ROI (Release of Information). On the ROI, please indicate Shelter name/address. By doing this, you are giving SAGE permission to contact shelter to verify information.Shelter Name:* Shelter Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Shelter Phone Number:*Section B: EmploymentEmployment Status: I am unemployed due to disability. This section does not apply to me. (Please provide copy of letter of eligibility for SSI – Supplemental Security Income or SSDI – Social Security Disability Insurance) I have never been employed. This section does not apply to me. I am financially supported by someone else. Name of Person Who is Financially Responsible for You:*(If you are not supported by a spouse or parent, please provide a notarized letter or Power or Attorney from/for the person who is financially responsible for you.) First Last Relation* Employment History:*Please provide at least 2.Name of EmployerAddress of EmployerHourly WageFull or Part TimeDates of Employment If you are currently unemployed and receiving unemployment benefits, please attach a copy of letter of eligibility. If you are currently unemployed and not receiving unemployment benefits, please provide copy of AZ Dept of Economic Security (DES) response letter. Drop files here or Select files Max. file size: 128 MB. Section C: Household InformationI reside in a homeless shelter. This section does not apply to me.* Yes No Including yourself please list any person(s) residing at the address you provided in section A. If you have included more than yourself, please provide page 1 of prior year Federal income tax return for Head of Household to verify household size.NameRelationship to the ApplicantDate of Birth Head of the Household:Head of Household Definition: An individual in one family setting who provides actual support and maintenance to one or more individuals who are related to him or her through adoption, blood, or marriage. First Last If household size is greater than 1(one), please provide page 1 of prior year Federal Income Tax Return for Head of Household if it is not Yourself Drop files here or Select files Max. file size: 128 MB. Section D: Monthly Household IncomeList all MONTHLY GROSS INCOME amounts from all sources for Yourself, your Spouse, and Head of Household.Wages, Salaries, Tips, etc.Self*Spouse*Head of Household*TotalSocial Security, Pension, Veterans’ BenefitsSelf*Spouse*Head of Household*TotalAlimony, Child SupportSelf*Spouse*Head of Household*TotalSupplemental Nutritional Assistance Program (SNAP, formally Food Stamps)Self*Spouse*Head of Household*TotalIncome from Business, Rent, Interest, DividendsSelf*Spouse*Head of Household*TotalOther IncomeSelf*Spouse*Head of Household*TotalUnemploymentSelf*Spouse*Head of Household*TotalTotal – SelfTotal – SpouseTotal – Head of HouseholdGrand Total*Section E: Supplemental Nutrtion Assistance (SNAP Formally Food Stamps)SNAP/Food Stamps* I receive state-funded nutritional assistance/food stamps. I do not currently receive state-funded nutritional assistance/food stamps. Amount recieved from SNAP/food stamps SNAP/Food Stamps received for a family of: Letter of EligibilityMax. file size: 128 MB.Section F: Verification DocumentsPlease provide the following verification documents where applicable and check the box indicating which documents you are providing.Please attach all of the following for yourself, your spouse, and your head of household. Missing documentation will delay the approval process. If Unemployed: Three (3) most recent payroll stubs or Prior Year Federal Income Tax Return Letter of Unemployment Benefits eligibility, starting monthly $ amount -or- that benefits were denied If currently Employed: (3) most recent payroll stubs are required Letter of Nutritional Assistance eligibility, stating monthly amount Other Applicable Documents Documentation for Self, Spouse, and Head of Household* Drop files here or Select files Max. file size: 128 MB. I certify that the household size and financial information presented in this application are true and accurate. I understand that SAGE Counseling will make efforts to verify the accuracy of this information. I further understand that SAGE Counseling is using this information exclusively for the purpose of determining whether I qualify for the Discounted Fee ProgramSignature*Name* First Last Date* MM slash DD slash YYYY Authorization for Release of InformationOnly required if living in residential shelterName* First Last DOB* MM slash DD slash YYYY Date* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneCellCase #* Purpose of disclosure*Please, leave the “other” selection checked in order for SAGE Counseling to verify your residence. Coordination with Probation/Parole/Court/Legal System Coordination with DES Coordination of Care Other: To verify residence Check boxes below to release, for the continuity of care and to maintain my medical record, protected health information related to any of the following or check ALL below, except progress notes, if ROI is for your referral source.*Please, leave the “Other” option checked so that SAGE Counseling may verify Shelter Residence. Assessments/Evaluations/Diagnoses Psychiatric/Mental Health Information Child Abuse/Neglect Oral Communication Progress Update Reports Progress Notes Discharge Summary Medical Information Treatment/Service Plans Alcohol and/or Drug Use Probation/Parole/Court/Legal Requirements Other: Shelter Residence verification, address, location, date of entry and expected length of residency. I understand that my protected health information may be used and disclosed to carry out treatment, for payment of services, or for healthcare operations to improve the quality of care by SAGE. I acknowledge receipt of the SAGE Notice of Privacy Practices and I understand that I have the right to review the Notice before signing this consent. I understand that any changes in the Notice will be posted at all SAGE sites and are available to me upon request. I understand that this authorization is in effect for one calendar year from the date on this form. The confidentiality of alcohol and/or drug abuse client records maintained by SAGE is protected by federal law and regulations. Except under special circumstances, SAGE may not orally disclose to a person outside the program that a client attends the program. SAGE also may not disclose any information identifying the client’s history of alcohol and/or drug abuse unless: by written authorization by the client; by written court order; or the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation process (Federal Law references 42 U.S.C. 290 dd-3 – Federal Regulation reference CFR, Part 2). I understand that I have the right to request in writing that SAGE restrict how my protected health information is used to carry out treatment, payment, or health care operations. I understand that SAGE is not required to comply with my request. I understand that I have the right to revoke in writing this authorization to release my protected health information.Client Name* First Last Client Signature*Client Signature Date* MM slash DD slash YYYY Legal Representative Name First Last Legal Representative SignatureLegal Representative Signature's Date MM slash DD slash YYYY Witness Name* First Last Witness Signature*Witness Signature Date* MM slash DD slash YYYY
