By clicking and signing below
• I acknowledge that the above and attached information is an accurate reflection of my household income. I understand that I am responsible for updating Set Free Alaska (SFA) of changes in income within 30 days. In addition, I understand that I am responsible for payment of services rendered at SFA, with or without a discounted rate.
• I permit the request for proof of income as noted above. I understand that more information may be required. All information provided will remain confidential under HIPAA federal regulations. Any discounts apply to all charges within the approved period for behavioral health and/or medical services provided by SFA.
If I qualify for Financial Assistance/discount:
• I understand that if I have not fully and correctly presented my household income or provided any false information, or if I have not disclosed my insurance coverage, I may lose or have a reduced discount rate. If I lose the discount, I agree to pay the balance on my account. I also agree to pay any legal fees for the collection process.
• I agree to repay any money if I receive other payment for the medical services covered. Such payments may include insurance payments, governmental program payments, and awards from a lawsuit.
• I agree to tell Set Free Alaska of any changes that could affect my eligibility, including changes to family size, income, and health insurance coverage. If I qualify for a public assistance program, I will apply to that program and provide Set Free Alaska with proof of application.
