Common use of Please attach copy of MEDS Clause in Contracts

Please attach copy of MEDS. Screen If client is Full scope Mcal, skip the remaining sections of this form and fax to MIS/Billing Unit – 573-2110 Is Client Potentially Eligible for Medi-Cal Benefits? □ Yes □ No Client Referred to Medi-Cal? □ Yes, give date: □ No Is this a Court-ordered Placement? □ Yes □ No‌ Does Client have Medicare? □ Yes □ No If yes, please check all that apply Part A Part B Part D (effective 1/1/06) What is the Client’s Medicare Number? Responsible Party’s Information (Guarantor): Name Phone Relationship to Client □ Self Address City State Zip Code □ Refused to provide Financial Information and will be charged full cost of service. FINANCIAL ASSESSMENT – Annual UMDAP (Uniform Method of Determining Ability to Pay) 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 ENTERED BY San Mateo County Mental Health Services Use Only 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.

Please attach copy of MEDS. Screen If client is Full scope Mcal, skip the remaining sections of this form and fax to MIS/Billing Unit – 573-2110 Is Client Potentially Eligible for Medi-Cal Benefits? □ Yes □ No Client Referred to Medi-Cal? □ Yes, give date: □ No Is this a Court-ordered Placement? □ Yes □ No‌ No Does Client have Medicare? □ Yes □ No If yes, please check all that apply Part A Part B Part D (effective 1/1/06) What is the Client’s Medicare Number? Responsible Party’s Information (Guarantor): Name Phone Relationship to Client □ Self Address City State Zip Code □ Refused to provide Financial Information and will be charged full cost of service. FINANCIAL ASSESSMENT – Annual UMDAP (Uniform Method of Determining Ability to Pay) 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… 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 □ 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 San Mateo County Mental Health Services Use Only ENTERED BY CLIENT ACCOUNT # DATA ENTRY DATE FAX COMPLETED COPY TO: MIS/BILLING UNIT (000)-000-0000 ENTERED BY San Mateo County Mental Health Services Use Only 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.

Please attach copy of MEDS. Screen If client is Full scope Mcal, skip the remaining sections of this form and fax to MIS/Billing Unit – 573-2110 Is Client Potentially Eligible for Medi-Cal Benefits? □ Yes □ No Client Referred to Medi-Cal? □ Yes, give date: □ No Is this a Court-ordered Placement? □ Yes □ No‌ Does Client have Medicare? □ Yes □ No If yes, please check all that apply Part A Part B Part D (effective 1/1/06) What is the Client’s Medicare Number? Responsible Party’s Information (Guarantor): Name Phone Relationship to Client □ Self Address City State Zip Code □ Refused to provide Financial Information and will be charged full cost of service. FINANCIAL ASSESSMENT – Annual UMDAP (Uniform Method of Determining Ability to Pay) 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. 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 ENTERED BY San Mateo County Mental Health Services Use Only 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.

Please attach copy of MEDS. Screen If client is Full scope Mcal, skip the remaining sections of this form and fax to MIS/Billing Unit – 573-2110 Is Client Potentially Eligible for Medi-Cal Benefits? □ Yes □ No Client Referred to Medi-Cal? □ Yes, give date: □ No Is this a Court-ordered Placement? □ Yes □ No‌ No Does Client have Medicare? □ Yes □ No If yes, please check all that apply Part A Part B Part D (effective 1/1/06) What is the Client’s Medicare Number? Responsible Party’s Information (Guarantor): Name Phone Relationship to Client □ Self Address City State Zip Code □ Refused to provide Financial Information and will be charged full cost of service. FINANCIAL ASSESSMENT – Annual UMDAP (Uniform Method of Determining Ability to Paypay) 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… 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 PersonDateReason 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 CLIENT AUTHORIZATION –This section is not required for Full scope Medi-Cal Clients ENTERED BY San Mateo County Mental Health Services Use Only 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. Instructions for Obtaining Medi-Cal Eligibility Using Internet ➢ Double click on Internet Explorer ➢ Type in the address box: xxxxx://xxx.xxxx-xxx.xx.xxx/eligibility ➢ From the Login Center Transaction Services screen, enter Userid: usually 5 zeros followed by your provider number ➢ Enter state assigned password – call Medi-Cal Provider Relations Phone Support @ 0-000-000-0000 ➢ Click on Submit or press enter ➢ From the Transaction Services screen, double click on Determine Patient’s Eligibility ➢ From Perform Eligibility screen fill in the following fields: ▪ Recipient ID – enter the client’s Social Security # (without dashes) ▪ Date of Birth – enter the client’s DOB (mm/dd/yyyy) ▪ Date of Card Issue – if unknown, enter today’s date (mm/dd/yyyy) ▪ Date of Service – enter the date on which the service is to be performed (mm/dd/yyyy) ▪ Click on Submit or press enter Note: Click on Back - to return to Transaction Services screen Clear – press this button to clear the fields in the form Patient Recall – once any transaction has been performed on a client, pressing this button will fill in the common fields with all of the information from the last transaction. This is useful for using the same client on different transaction (such as an eligibility verification, then a Share of Cost) or for correcting data when a transaction has gone through with incorrect data.

Please attach copy of MEDS. Screen If client is Full scope Mcal, skip the remaining sections of this form and fax to MIS/Billing Unit – 573-2110 Is Client Potentially Eligible for Medi-Cal Benefits? □ Yes □ No Client Referred to Medi-Cal? □ Yes, give date: □ No Is this a Court-ordered Placement? □ Yes □ No‌ No Does Client have Medicare? □ Yes □ No If yes, please check all that apply Part A Part B Part D (effective 1/1/06) What is the Client’s Medicare Number? Responsible Party’s Information (Guarantor): Name Phone Relationship to Client □ Self Address City State Zip Code □ Refused to provide Financial Information and will be charged full cost of service. FINANCIAL ASSESSMENT – Annual UMDAP (Uniform Method of Determining Ability to Pay) 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… 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) Insurance Co. phone number State Zip City Street Address Health Plan or Insurance Company (Not employer) Name of Company Attachment D. Payor Financial Form Does this Client have Healthy Families Insurance? □ Yes □ No Does this Client have Healthy Kids 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 tre 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 res 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. Cou _ 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)-000-0000 ENTERED BY ENTRY DATE San Mateo County Mental Health Services Use Only 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.. Instructions for Obtaining Medi-Cal Eligibility Using Internet ➢ Double click on Internet Explorer ➢ Type in the address box: xxxxx://xxx.xxxx-xxx.xx.xxx/eligibility ➢ From the Login Center Transaction Services screen, enter Userid: usually 5 zeros followed by your provider number ➢ Enter state assigned password – call Medi-Cal Provider Relations Phone Support @ 0-000-000-0000 ➢ Click on Submit or press enter ➢ From the Transaction Services screen, double click on Determine Patient’s Eligibility ➢ From Perform Eligibility screen fill in the following fields: ▪ Recipient ID – enter the client’s Social Security # (without dashes) ▪ Date of Birth – enter the client’s DOB (mm/dd/yyyy) ▪ Date of Card Issue – if unknown, enter today’s date (mm/dd/yyyy) Attachment D – Payor Financial Form ▪ Date of Service – enter the date on which the service is to be performed (mm/dd/yyyy) ▪ Click on Submit or press enter Note: Click on Back - to return to Transaction Services screen Clear – press this button to clear the fields in the form Patient Recall – once any transaction has been performed on a client, pressing this button will fill in the common fields with all of the information from the last transaction. This is useful for using the same client on different transaction (such as an eligibility verification, then a Share of Cost) or for correcting data when a transaction has gone through with incorrect data. Attachment D – Payor Financial Form Instructions for Clearing Medi-Cal Share of Cost Using Internet ➢ Double click on Internet Explorer ➢ Type in the address box: