Sliding Fee Schedule

*If the income level is low enough to qualify for the above “Nominal” fee scale, please arrange for the client to apply for TennCare and/ or Behavioral Health Safety Net Funding.  BHSN eligibility is limited to available funds and assigned diagnosis.  If the client does not qualify for TennCare/ BHSN and the annual income is under $3,000, a zero reduced fee will apply.

• Eligibility for the “Nominal” Fee Schedule must be approved on a monthly basis.
• Payment is expected at the time services are rendered, except under unusual circumstances.
• Fee reduction that is granted is based upon lack of third party/ insurance coverage.  If insurance or other  reimbursement sources are available, are not eligible for the sliding-fee scale.
• Professional Care Services of West TN, Inc. reserves the right to change fees, at which time a new contract will be required.

Documentation for a Reduced Fee may include:

• Income Tax Statement
• DHS Report
• Employer/ Pay Check or Stub
• SS Statement
• Unemployment Statement
• Retirement/ Pension Statement
• Child Support Statement
• # in household (a group of 2 or more related by birth, marriage, or adoption and residing together)

Other sources of income may include workers’ compensation; public assistance; veteran’s payments; survivor benefits; income from interest, dividends, rents, royalties, estates, trusts, education assistance, alimony; any income from outside the household and other sources.  Noncash benefits (such as food stamps and housing subsidies) do not count towards income.

Behavioral Health Services NOT eligible for a reduced fee:

• Psychological Testing Per Hour (for both interview and writing time)
• Court Appearance/ Deposition Per Hour (1 hour minimum charge up to the stated fee)
• Alcohol and Drug Assessment Per Hour (1 hour minimum)
• Crisis Intervention
• Crisis Respite Bed Per Day

*Lab service rates are based upon the tests performed