top of page
Green Nature

Forms

Sliding Fee Application

We understand that hard financial times can occur as a result of trying to recover from the disease of addiction. If you have thought about discontinuing your treatment due to your financial burdens, please first consider completing a sliding fee form from our program based on financial documentation of your current income.

 

The documentation that is needed to see what sliding fee category you fit into are the following:

 

  • Current Pay Stubs

  • Last Year’s Tax Return

  • Social Security/Disability Check Stubs 

  • Unemployment Check Stubs

Authorization to Obtain/Disclose Health Information

If you wish to submit a Sliding Fee Application or obtain records please select from the appropriate forms.  You can also fill out a credit  card authorization form for future payments.  After accessing your form please complete and submit below...

Please contact Kaitlyn with any questions regarding our record release forms. 517-599-4894.

Email: Freedomclinic@hotmail.com

Email: Freedomrecovery.mi@gmail.com

Fax: 989-340-1512

 

bottom of page