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A close-up side view of stacked coins against a muted grey background, their ridged edges catching a subtle brass tone, representing the financial assistance application process in the Sliding Scale Application at Availia.

Sliding Scale Application

Apply for a reduced-fee rate. Supporting documentation is required. Eligibility is determined by 200% Federal Poverty Level.

Please Note:

This application is for clients seeking a reduced-fee rate based on limited income.

 

Complete & submit this form along with supporting documentation before or at your first appointment.

 

Applications cannot be approved without documentation.

 

Supporting documents may be uploaded via the Document Uploads page,

emailed to info@availia.com, or brought to your appointment.

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Availia Client Information

Date of Birth
Month
Day
Year

Residence & Household

Total # of People in Household

Client Income & Documentation

Client's Primary Income Sources

NOTICE: Applications without supporting documents are not approved. Documents may be provided in-person, by email at [info@availia.com], or by simple upload using the Document Uploads page on our site.

Supporting Documents to be Uploaded/Provided

Client Attestation

I attest that the information provided on this application is true, accurate, & complete to the best of my knowledge. I understand that providing false or misleading information may result in my rate being adjusted to the standard rate, with potential for any difference to be billed retroactively. I agree to notify Availia of any significant change in my household size or income. I understand that my eligibility status remains in effect unless I report a change or request a review.

Availia TeleHelp PLLC and signee agree that any digital signature

may serve the full legal effect and function of a handwritten signature.

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