Sliding Fee Discount Program Patient Application

It is the policy of Healthy Mind Foundation to provide essential services regardless of the patient’s ability to pay. Healthy Mind Foundation offers discounts based on family size and annual income.

Please complete the following information and return it to the front desk to determine if you or members of your family are eligible for a discount. The discount will apply to all services received at this clinic, but not those services or equipment purchased from outside, including reference laboratory testing, drugs, x-ray interpretation by a consulting radiologist, and other such services. You must complete this form every 12 months or if your financial situation changes.