Behavioral Health Fund Application

    San Miguel Behavioral Health Solutions Panel (Panel) created the Behavioral Health Fund (SMBH Fund), which is intended to help those living and/or working in San Miguel County to be able to afford individual mental health counseling/therapy services. Please complete this application below to apply for a financial scholarship in the form of a copay. Your completed application will be reviewed to determine your copay for counseling/therapy based on current yearly family income (see Sliding Scale below). The Panel will cover the remaining balance of your counseling/therapy session. Your therapist must agree to bill the Panel for services provided. This application is good from now until the end of 2022 unless your income, residence, or place of work changes.

    If you would prefer to complete a paper application you can print out THIS PDF, fill it out by hand, scan it back in, and send the completed document, along with your proof of income documentation, to BHFUND@tchnetwork.org.

    Every section of this application must be completed in its entirety. Incomplete applications will not be considered.

    sliding-scale

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    Demographics

    Financial Information

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    *Provide projections as necessary

    Proof of Income

    You must provide one of the following for EACH person contributing to your annual household income:

    • Pay Stubs for the Last Two Months of Work
    • Proof of Unemployment, as applicable
    • Profit and Loss Statements (if self-employed)

    Each file must be either jpg, jpeg, png, gif, pdf, doc, or docx with a maximum file size of 890KB. If your documents are too large or you are having issues uploading them you can email them as attachments to bhfund@tchnetwork.org. Please be sure to include your name and what each attached document is for.

    6a. Yourself

    Pay Stubs for the Last Two Months of WorkProof of UnemploymentProfit and Loss Statements (if self-employed)

    6b. Contributor #2

    Pay Stubs for the Last Two Months of WorkProof of UnemploymentProfit and Loss Statements (if self-employed)

    6c. Contributor #3

    Pay Stubs for the Last Two Months of WorkProof of UnemploymentProfit and Loss Statements (if self-employed)

    6d. Contributor #4

    Pay Stubs for the Last Two Months of WorkProof of UnemploymentProfit and Loss Statements (if self-employed)


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    EmailPhone

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    Electronic Signature Agreement

    I certify, to the best of my knowledge, that all information in this application is true and accurate. Furthermore, I agree to inform Tri-County Health Network if my family income, county of residence, or my place of work changes at any point of the year. I understand that there is no guarantee I will receive a financial scholarship. Finally, I understand that, if I receive a financial scholarship, in order for my care to be paid, I authorize my therapist to release the dates/times of my treatment and reason for visit - for payment purposes only. Any personal information that could identify me will be changed before this information is shared with Solutions.

    The parties agree that this agreement may be electronically signed. The parties acknowledge that electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability and admissibility.

    (Use your mouse or trackpad to sign.)

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