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.
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 ser...
