Sliding Fee Scale Application
INSTRUCTIONS
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The Sliding Fee Scale may give you a discount on services at LifeWays.
A completed Sliding Fee Scale Application is a requirement of the Michigan Mental Health Code at admission and must be completed annually and/or if income or insurance changes.
All information provided will be kept confidential.
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Complete Sliding Fee Scale Application.
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Sign the Sliding Fee Scale Application.
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Upload proof of ALL income for ALL household members over the age of 18.*
You must provide one of the following documents for proof of household income:
Most current Federal Income Tax Return(s)
Most recent W-2's
One month of most recent household pay-stubs
Award letters from Social Security, pensions, annuities, trust funds (if applicable), and/or one month of most current Unemployment statements or check stubs
If you cannot provide one of the above, please include the last 3 months bank statements showing income received.
*If you are married, you must provide yours and your spouse’s proof of income.
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Submit your application and all supporting income documentation by using this online form.
Paper applications are available by request at the front desk.
You can also download a PDF application and mail it with your supporting documentation to 1200 N. West Ave., Jackson MI 49202 by clicking here.