Financial Policy Agreement

I authorize Knik Tribe and/or Benteh Wellness Center to release any information necessary concerning my or my child’s diagnosis and treatment to insurance carriers and/or their agents for the purpose of securing payment on this account.

• I authorize my or my child’s insurance benefits to be paid directly from the insurance carriers to Knik Tribe and/or Benteh Wellness Center.

• I understand that should any insurance payment be made to me or my child for a balance due on this account, I will immediately bring in and sign these checks over to Knik Tribe. (This is common with the Blue Cross Federal Employee Program). I understand that an "out of network" insurance carrier may limit payments for any or all services provided by Knik Tribe and/or Benteh Wellness Center.

• I understand that Knik Tribe and/or Benteh Wellness Center staff cannot guarantee insurance eligibility and coverage. It is my responsibility to check my or my child’s behavioral health benefits prior to my appointment. A list of current fees and my estimated costs will be presented as part of the intake process.

• I assume responsibility for any deductible, copay and coinsurance, as well as any other balance not covered by the insurance carrier, and that these fees are due at time of service. All Participants who present without valid insurance information are considered to be self-pay accounts.

• I understand that arrangements can be made if I am unable to meet my financial obligations. I will need to contact the Knik Tribe/Benteh Wellness Center billing department to review the payment options. Unpaid accounts may be considered for 3rd Party Collections.

• I understand that Knik Tribe and/or Benteh Wellness Center offers a sliding fee discount program. To take advantage of this discount program, I must provide proof of income on at least an annual basis or sooner if my income changes. If I fail to provide proof of income in a timely manner, I will be responsible for full fees.

I have read the statements above and understand my financial responsibility. If I have additional questions, I will speak to a staff member before my appointment.

Sliding Fee Scale Application

*Please ask for assistance for families larger than 6 members

Family Size = $0 Co-Pay (100% FPG)

1 = $0- $1,567

2 = $0- $2,127

3 = $0- $2,688

4 = $0- $3,249

5 = $0- $3,810

6 = $0- $4,371

Each Additional +$561

Family Size = $5 Co-Pay (200% FPG)

1 = $1,568 - $3,134

2 = $2,128 - $4,256

3 = $2,689 - $5,377

4 = $3,250 - $6,499

5 = $3,811 - $7,621

6 = $4,372 - $8,742

Each Additional +$1,122

Family Size = $10 Co-Pay (300% FPG)

1 =  $3,135 - $4,702

2 = $4,257 - $6,384

3 = $5,378 - $8,067

4 = $6,500 - $9,749

5 = $7,622 - $11,432

6 =  $8,743 - $13,114

Each Additional +$1,683

Family Size = $20 Co-Pay (400% FPG)

1 = $4,703 +

2 = $6,385 +

3 = $8,068 +

4 = $9,750 +

5 = $11,433 +

6 = $13,115 +

Each Additional +$2,244

I understand that the information I provided on this form is subject to verification by BWC/Knik Tribe. I authorize this clinic to disclose this information to qualify me/my child for reduced fees. I certify that the above information is true and correct to the best of my knowledge. Any changes in income will be reported immediately so I can update income documentation.

Service Price Unit

• Mental Health Intake Assessment $300.00 Per Assessment

• Psychotherapy, Individual 16-37 mins $100.00 Per Session

• Psychotherapy, Individual 38-52 mins $135.00 Per Session

• Psychotherapy, Individual 53-60 mins $170.00 Per Session

• Psychotherapy, Family 30 mins $100.00 Per Session

• Psychotherapy, Family 60 mins $170.00 Per Session

• Psychotherapy, Multi-family Group 30 mins $50.00 Per Session

• Psychotherapy, Multi-family Group 60 mins $100.00 Per Session

• Psychotherapy, Group 30 mins $50.00 Per Session

• Psychotherapy, Group 60 mins $100.00 Per Session

• Case Management $50.00 Per 15 Mins

• Peer Based Crisis Services $50.00 Per 15 Mins

• Home Based Family Treatment $50.00 Per 15 Mins

• Community Recovery Support (individual) $50.00 Per 15 Mins

• Community Recovery Support (group) $50.00 Per 15 Mins

• Treatment Plan Development/ Review $150.00 Per Review

Approved Documentation to show Proof of Income:

• Most recent W2 tax form(s)

• Most recent completed tax return

• Three most recent paystubs

• Document(s) from Public Assistance, Unemployment, Social Security, etc. stating income

Contact Information:

Unemployment

Toll Free: 888-252-2557

Public Assistance

855 W Commercial Dr

Wasilla AK 99654

Phone: 907-376-3903

Toll Free: 800-478-7778

hss.dpa.offices@alaska.gov

Internal Revenue Service

949 E 36th Avenue

Anchorage AK 99508

Phone: 907-271-6391

Social Security Administration

222 W 8th Avenue, Room A11

Anchorage AK 99513