Sliding Scale Application - Kemper Pelvic Physio

Thank you for your interest in our pelvic floor physical therapy services. At Kemper Pelvic Physio, we are committed to providing accessible and trauma-informed healthcare services to everyone. Our sliding scale policy is designed to ensure that individuals from all walks of life can access the care they need.

We welcome all individuals regardless of their financial situation, and encourage those who may face financial challenges to utilize this policy. Additionally, we are committed to addressing health disparities and promoting inclusivity in healthcare.

Please take a few moments for thoughtful completion of this entire form so that we can better understand your needs and provide you with the best possible care. Once completed, please click the “Submit” button. We will review your information and reach out to you as soon as possible to discuss scheduling an appointment. We are committed to supporting you on your journey to better pelvic health and overall well-being. Thank you for entrusting us with your healthcare needs.

Sliding Scale Tiers

There are a select number of slots available for each category below. Sliding Scale means that the rates for services will vary between three payment tiers.

Consider how you fit in each of these tiers. When you fill out the form below, you’ll select the category you feel is most appropriate and would also be a commitment for you. Some may not fit neatly into any individual category. Please consider the closest fit for your situation.

In all cases, but especially if your situation crosses multiple categories, we will consider all responses in totality to determine eligibility.

Tier 1	Tier 2	Tier 3
Own home in desired location or rent higher end property	Own or rent in a low or middle income area	Rent in a low income area and/or have to have roommates
Own or lease a vehicle or use rideshare	Have to use rideshare or public transportation	Required to use public transit or rely on others for transportation
Have expendable income and can buy new items, take a vacation or save for future	Can plan and sometimes save for items, but difficult to save/plan for future; able to vacation every few years	No discretionary income for items or ability to save toward future; little to no travel ability
Can easily afford health care services	Healthcare expenses are a challenge, but manageable	Regularly cannot use healthcare because it’s prohibitively expensive
Have no dependents and/or able to easily support dependents	Have dependents and their support takes a large amount of time and income	Have dependents and sometimes struggle to support them
Have had good or a few negative experiences with healthcare providers, but that does not prevent you from seeking care	Have had a few negative experiences with healthcare providers which may or may not alter you seeking care	Have had multiple negative experiences with healthcare providers which has made you not seek care
$275	$165	$85

*Prices shown are for the hourly follow-up sessions. Initial evaluation visits are $295, $180 and $90.*

Application Form

Name *

Date of Birth / Age *

Zip Code *

Email *

Phone Number *

How did you hear about us?

Referred by?

Briefly describe why you are seeking an appointment at Kemper Pelvic Physio. Please note how long you've been experiencing these symptoms. *

Please review the Sliding Scale Table above, and choose a tier. You'll be able to explain your reasoning below. *

Please share how you came to identify that tier as most appropriate to you. *

Please describe any aspects of your identity that you feel are relevant to your healthcare experience.

What else do you want us to know?

Are there any questions we can answer for you?

Consent and Privacy *

I agree

By submitting this form, you acknowledge that all information provided will be kept confidential and used solely for the purpose of providing healthcare services. You acknowledge that you understand and agree with the terms of the Sliding Scale.

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