Scholarship, Payment Plans, and/or Insurance

Once your evaluation appointment is scheduled, we will be able to accept your application for alternative funding sources such as scholarship, payment plans, and/or insurance. Some insurance companies reimburse a portion of the fees. As we have seen such good results with AIT, we are committed to making it available to anyone who is qualified for the program.

Scholarship / Subsidy / Grant Opportunities

When you submit a scholarship application, we ask that you also look into other possible sources of financial support in your community. For example, please contact your local church or synagogue, other family members, or service organizations such as Kiwanis, Rotary, or Lion's Club to inquire about any grants or support that they might be willing to provide.

Insurance Coverage

Our staff can contact your insurance program to request information regarding eligibility and terms of coverage. If you send us your insurance forms prior to your evaluation, we will work to provide you with information regarding expected insurance coverage at the time of the evaluation. Please understand that while we will investigate insurance coverage for you, we can not guarantee payment by your insurance company. Any fees not covered by insurance or scholarship are, of course, the responsibility of the client or guardian.

Do not hesitate to call us for further information or assistance: 828-683-6900.

Scholarship, Payment Plans, and/or Insurance

*Required fields, please
Applicant Information
Date*		Date of Birth
Name of Applicant*
Occupation
Name of Spouse or Parent		Occupation
Address
City & State		Zip/Postal Code
Country (if not US)
Home Phone		Work Phone
Email Address
Number of People in Household
Insurance Information
Primary Insurance Information
Name of Insured		Date of Birth
Insurance Company
Insurance ID#		Group #
Phone # of Insurance
Secondary Insurance Information
Name of Insured
2nd Insurance Company
Insurance ID#		Group #
Phone #
Scholarship Information
Gross Income
	Monthly		Yearly
Self
Spouse
Others
Other Sources
Alimony
Childcare
Rental
Government
Total
Expenses
	Monthly		Yearly
Mortgage
Rent
Utilities
Alimony
Childcare
Medical
Education
Credit Card
Other
Please explain:
Total
Net
Do you need a payment plan?	Yes No
If so, how much can you budget to pay on a monthly basis?
Please note any attempts made to secure other funding sources and other special circumstances that you would like us to take into consideration.

Note: This form is strictly confidential. The completion of this form in no way obligates you or the practitionerto perform AIT. It is only to help us determine what is in the best interest of the applicant.