Common use of Financial Assessment Clause in Contracts

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/HEALTHY KIDS/HEALTH WORKS ELIGIBLITY Below are instructions for accessing the State’s MEDS (Medi-Cal Eligibility Determination System) to determine eligibility and clearing share of cost through the internet If you do not have access to the internet, please call Xxxxxxxxxx Xxxxx (phone: 000-000-0000) or Xxxxxxx Xxxxxx (phone:000-000-0000) to verify eligibility.

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 bill 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/HEALTHY KIDS/HEALTH WORKS ELIGIBLITY Below are instructions for accessing the State’s MEDS (Medi-Cal Eligibility Determination System) to determine eligibility and clearing share of cost through the internet If you do not have access to the internet, please call Xxxxxxxxxx Xxxxx (phone: 000-000-0000) or Xxxxxxx Xxxxxx (phone:000-000-0000) to verify eligibility.

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/HEALTHY KIDS/HEALTH WORKS ELIGIBLITY Below are instructions for accessing the State’s MEDS (Medi-Cal Eligibility Determination System) to determine eligibility and clearing share of cost through the internet If you do not have access to the internet, please call Xxxxxxxxxx Xxxxx (phone: 000-000-0000) or Xxxxxxx Xxxxxx (phone:000-000-0000) to verify eligibility.

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/HEALTHY KIDS/HEALTH WORKS ELIGIBLITY Below are instructions for accessing the State’s MEDS (Medi-Cal Eligibility Determination System) to determine eligibility and clearing share of cost through the internet If you do not have access to the internet, please call Xxxxxxxxxx Xxxxx (phone: 000-000-0000) or Xxxxxxx Xxxxxx (phone:000-000-0000) to verify eligibility.

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 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. □ No Does this Client have Healthy Kids Insurance? □ Yes □ No Does this Client have HealthWorx Insurance.? □ Yes □ Yes □ No CLIENT AUTHORIZATION –This section is not required for Full scope Medi-Cal Clients □ No 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 AUTHORIZATION –This section is not required for Full scope Medi-Cal Clients 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)-000-0000ENTERED BY 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/HEALTHY KIDS/HEALTH WORKS ELIGIBLITY Below are instructions for accessing the State’s MEDS (Medi-Cal Eligibility Determination System) to determine eligibility and clearing share of cost through the internet If you do not have access to the internet, please call Xxxxxxxxxx Xxxxx (phone: 000-000-0000) or Xxxxxxx Xxxxxx (phone:000-000-0000) to verify eligibility.

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)-000-0000ENTERED BY 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/HEALTHY KIDS/HEALTH WORKS ELIGIBLITY Below are instructions for accessing the State’s MEDS (Medi-Cal Eligibility Determination System) to determine eligibility and clearing share of cost through the internet If you do not have access to the internet, please call Xxxxxxxxxx Xxxxx (phone: 000-000-0000) or Xxxxxxx Xxxxxx (phone:000-000-0000) to verify eligibility.