Prodigy Healthcare - Substance Abuse Counseling and Alcohol Treatment

Welcome to the Prodigy Healthcare Fee Reduction Request page.

This page is designed to provide clients from certain contracted referral sources an opportunity to receive our services with a lowered financial burden. Any fee reductions are funded directly by Prodigy Healthcare and we are not in any way, shape, or form reimbursed or funded by the court / government. We are a small family-run business and will review every request thoroughly in order to prevent fraud and keep providing these services to those truly in-need of assistance.

Please understand that not everyone will qualify and fee reductions, if granted, are not retroactive. Be sure to read all Terms and Conditions, including legal attestations, at the end of the form. They are important! Abuse of this program will not be tolerated.

Step 1 of 6

Prerequisite

Have You Completed a Screening Appointment, Yet, for the Charge in Which You Are Applying for a Fee Reduction? *

Please Read Carefully!

Checkboxes *

I Agree to the Terms

By submitting this form, I understand that it does not guarantee approval of any reduction and I agree to continue paying for, and attending, groups at the current price until a determination has been made. I further understand that Fee Reductions are not available to all clients and that Prodigy Healthcare provides this self-funded financial assistance program for certain contracted referral sources based upon a predetermined qualification matrix. The system has the ability to determine eligibility and will automatically make determinations based upon programmed logic. I agree that I will honor my obligations to this program, should my Fee Reduction Request be denied. I also understand that I may not reapply for a Fee Reduction until 6 months have passed from the day of submittal, and that I can prove a material change in circumstances. No Fee Reduction Requests will be granted for clients with an outstanding balance. If you receive a reorder to return to the program, then you may be required to reapply for this program. If approved, Fee Reductions are not retroactive.

Digital Signature *

First

Middle

Last

By my signature above, I certify that the statements and information provided in this form are true, accurate and complete and I also understand that any false statements or deliberate omissions on this form may subject me to legal actions for fraudulent misrepresentation. By submitting this form, I further agree to provide all supporting documentation for the information provided in this form, as requested, or my application will de denied.

Fee Reduction Request

Prerequisite

Client Information

Income

Housing

Expenses

Please Read Carefully!