APPLICATION FOR MENTAL HEALTH CLIENT ASSISTANCE PROGRAM
CONSENT FOR THE RELEASE OF INFORMATION
FR0070-Application-for-Financial-Assistance.
FR0114FI Release of Information-PCP
APPLICATION FOR MENTAL HEALTH CLIENT ASSISTANCE PROGRAM
CONSENT FOR THE RELEASE OF INFORMATION
FR0070-Application-for-Financial-Assistance.pdf
Southern Minnesota Behavioral Health will work with you to help you meet your obligations to pay for and continue to receive services. Please complete and sign this application, check the appropriate boxes below, and include all necessary documentation. If you qualify, you must first apply for an assistance program discount. All information provided here will be kept confidential.