Financial Assessment. Annual UMDAP (Uniform Method of Determining Ability to Pay) To determine family’s UMDAP liability, please list any other family members currently being seen by Mental Health: Gross Monthly Income (include all in the Household) A. Self $ B. Parents/Spouse/Domestic Partner ….$ C. Other $ Number of Persons Dependent on Income Allowable Expenses A. Court Ordered Monthly Obligation $ B. Monthly Child Care Payments(Only if Necessary for Employment) $ C. Monthly Dependent Support Payments $ D. Monthly Medical Expense Payments $ E. Monthly Mandated Deductions for Retirement Plan (Do not include Social Security)… $ F. Housing Cost (Mortgage/Rent) $ Asset Amount (List all liquid assets) A. Savings… $ B. Checking… $ C. Stocks… $ 3rd Party HEALTH INSURANCE INFORMATION Health Plan or Insurance Company (Not employer) Name of Company Street Address City State Zip Insurance Co. phone number Policy Number Group Number Name of Insured Person Relationship to Client Social Security Number of Insured Person (if other than client) Does this Client have Healthy Families Insurance? □ Yes □ No If Yes, complete San Mateo County Mental Health SED form. Does this Client have Healthy Kids Insurance? □ Yes □ No Does this Client have HealthWorx Insurance.? □ Yes □ No CLIENT AUTHORIZATION –This section is not required for Full scope Medi-Cal Clients I affirm that the statements made herein are true and correct. I understand that I am responsible for paying the UMDAP liability amount or cost of treatment received by myself or by members of my household during each 1-year period. If the cost of service is more than the UMDAP liability amount, I pay the lesser amount. It is my responsibility and I agree to provide verification of income, assets and expenses. If I do not, I will be billed in full for services received. I authorize San Mateo County Mental Health to xxxx all applicable mental health services to Medi-Care and/or my insurance plan, including any services provided under 26.5. I authorize payment of healthcare benefits to San Mateo County Mental Health. Signature of Client or Authorized Person Date Reason if client is unable to sign Client Refused to Sign Authorization: 🞏 (Please check if applicable) Date Reason Name of Interviewer Phone Number Best Time to Contact FAX COMPLETED COPY TO: MIS/BILLING UNIT (000)-000-0000 San Mateo County Mental Health Services Use Only ENTERED BY CLIENT ACCOUNT # DATA ENTRY DATE Attachment D - Payor Financial Form MEDI-CAL AND HEALTHY FAMILIES/HEAL...
Financial Assessment. Activities re- lated to determining a noncustodial parent’s ability to provide support.
Financial Assessment. 14.3.1 CONTRACTOR shall conduct a Financial Assessment with PARENTS using a sliding fee schedule provided by ADMINISTRATOR to determine fees that PARENTS may be able to pay, for services received.
Financial Assessment. 12.3.1 CONTRACTOR must inform and include in all client service contracts that the client may request CONTRACTOR to conduct a financial assessment in accordance with these standards to determine his/her ability to pay program fees.
Financial Assessment. 7.15.1 CONTRACTOR shall conduct a Financial Assessment with adult CLIENTS, using a sliding fee schedule provided by ADMINISTRATOR to determine fees that adult CLIENTS may be able to pay for services received.
Financial Assessment. CONTRACTOR shall conduct a Financial Assessment with adult CLIENTS using a sliding fee schedule provided by ADMINISTRATOR, to determine fees for services that adult CLIENTS may be able to pay, for services received. However, CONTRACTOR shall not refuse services to CLIENTS referred by ADMINISTRATOR because of inability or unwillingness to pay.
Financial Assessment. See the Compliance with DMC and Requirements Exhibit, attached hereto, for Applicable Fees (Section 20.3).
Financial Assessment. Our proprietary assessment is designed to uncover opportunities, troubleshoot problems, and create a customized plan to ensure operational excellence. The assessment will focus on resource deployment, services provided by each entity, and research of various models from other destinations. This assessment will identify areas that are working well, highlight areas for improvement, and most importantly, provide expert recommendations on the path to success.
Financial Assessment. CONTRACTOR, upon intake, shall identify clients who are Medi-Cal eligible or have other means to pay, or contribute to, an approved sliding fee co-payment, and if DMC- certified, shall bill Medi-Cal for services before using other funding. • CONTRACTOR shall set fees for non-Medi-Cal clients, determine client’s ability to pay, collect fees (as payment or co-payment) from clients, and bill private insurance, the County, or Medi-Cal as appropriate. • If the client is determined to be Medi-Cal eligible and the CONTRACTOR is not a Drug Medi-Cal certified CONTRACTOR, the client shall not be accepted into the program but shall instead be referred to a Drug Medi-Cal program. • The program must inform and include in all client service contracts that: A client may request the program to conduct a financial assessment in accordance with these standards to determine his/her ability to pay program fees. The program may not deny services to client if, based on the results of financial assessment, the program determines that the client is unable to pay the program fee. For Drug Medi-Cal certified CONTRACTORs, in no case is a qualified Medi-Cal client who is pregnant or less than 60 days postpartum to be charged for any residential treatment. • A sliding fee scale shall be utilized. The program must assess the client program fee and set the payment schedule based on the client’s documentation of income. • The program must maintain in the client records a copy of all financial assessments and documentation of income provided by the client.
Financial Assessment. The CONTRACTOR must inform and include in all client service contracts that the client may request the CONTRACTOR to conduct a financial assessment in accordance with these standards to determine his/her ability to pay program fees. • A sliding fee scale shall be utilized. The CONTRACTOR must assess the client program fee and set the payment schedule based on the client’s documentation of income. • The CONTRACTOR must maintain in the client records a copy of all financial assessments and documentation of income provided by the client.
