A Renal Participation Fee Worksheet

Section 148.TABLE A   Renal Participation Fee Worksheet Date Initialed Patient Identification Number PATIENT’S NAME Last First Middle Initial In questions 1 through 4 below, please circle one number or group of numbers: 1. NUMBER OF PERSONS IN FAMILY 1 2 3 4 5 6 or more 2. NUMBER OF CHILDREN 1 2 3 4 5 or more 3. AGE OF OLDEST CHILD IN YEARS 0-5 6-15 16-17 18 and over 4. AGE OF HEAD OF HOUSEHOLD Under 35 35-54 55-64 65 and over BUREAU OF LABOR STATISTICS (BLS) EQUIVALENCE FACTOR= (see Table B) A. LOCATION (See Table C, List of Metropolitan Counties by SMSA Definition) BLS METRO = $12,815 BLS NON-METRO = $11,604 B. STANDARD BUDGET BLS EQUIVALENCE BLS STANDARD FAMILY STANDARD FACTOR BUDGET BUDGET $ X $ = $ (metro or non-metro) C. PARTICIPATION DETERMINATION ADJUSTED GROSS FAMILY STANDARD INCOME BUDGET $ - $ = $ X .333 = $ D. ADJUSTED GROSS INCOME $ X .125 = $ LESSER OF C or D = $ E. ADJUSTED GROSS INCOME = $ FAMILY STANDARD BUDGET = $ (B. above) F. FEDERAL INCOME TAX STATE INCOME TAX TOTAL TAX $ + $ = $ TOTAL TAX BLS STANDARD TAX $ - $ = $ (metro $1,435) (non-metro $1,260) G. SPECIAL CARE FOR CHILDREN $ H. SCHOOL TUITION $ I. FAMILY SUPPORT PAID $ J. OTHER PAYMENTS 1. Transportation to and from dialysis $ 2. Employment Expense (dues, uniforms, small tools) $ SOCIAL SECURITY BSL STANDARDS $ - $ = $ (metro $702) (non-metro $676) K. MEDICAL EXPENSES BLS STANDARD MEDICAL EXPENSES ALLOWED $ - $ = $ (includes medical (metro $876) insurance premiums) (non-metro $671) MEDICAL EXPENSES TOTAL EXPENSES INCOME IN EXCESS ALLOWED $ - $ = $ (E through K totaled, less adjusted gross income) L. INCOME IN EXCESS $ X     .333 = $ M. ENTER SMALLEST AMOUNT OF C or D or L $