Most of the information on this form is requested of the guarantor: the person who is financially responsible for the client. When the client is 18 years of age or older and has not been assigned a guardian by the court, the guarantor and client are the same (even if the client is a dependent on a parent's taxes or on a parent's health insurance: if they are 18 years of age or older, they are still the financially responsible party). The information collected by this form is stored directly in the practice's HIPAA-compliant Google Cloud. All required questions must be answered to be considered for reduced fee.

If the client is a minor, the guarantor is the parent or guardian. If the client is a foster child, this is not the form to be using: services must be billed through Medicaid. If the client is a minor, you must be able to prove you are the parent, have custody or guardianship. On or immediately following a client's 18th birthday, this form and the Informed Consent Agreement must be re-executed.

If the client is a dependent adult who must have assistance filling out the form, whether or not they have a guardian, the information provided should be about the client themselves where it asks for "guarantor", but the guardian or advocate who fills out the form should provide their own phone number and email, for communication purposes.

Eligibility for reduced fees are based on the US Federal Poverty Guidelines website: https://aspe.hhs.gov/poverty-guidelines.  If your income is less than 300% of the Federal Poverty Guideline for your household size, you are eligible for a reduced fee.   Please refer to Connection Is, PLLC's website for the company policy: https://www.mwcftc.com/fees

Please submit this completed application and forward 2 recent pay stubs, or 2 bank statements, or receipts ledger for two months (if self employed in a cash-based business) via email to anne@mwcftc.com or faxed to 319-774-0344 for income verification.

Completion of this form indicates agreement to share the information given. Filling out this form is not required to receive services, only to be considered for a reduced fee. All information given is subject to HIPAA and will be kept confidential.