Financial Information Form

EXHIBIT A Adj. Annual Income In Family 7+ Under To To To To To To To To To To To To To To 105 CNR: DEPARTMENT OF PUBLIC HEALTH Adj. Annual Income In Family 7+ To To To To To To To To To Add *83.00 for each additional $1,000 +83 +83 +83 +83 +83 +83 +83 +83 EXHIBIT B HUMAN SERVICES FINANCIAL INFORMATION FORM Name: SS No. Birth date: Sex: Former Patient: Marital Status: Patient Address: Name Financially Responsible Individual #1 (if different from above) Address: Relationship: SS No. Name Financially Responsible Individual #2 Address: Relationship: SS No. If there are any additional number of Financially Responsible Individuals list names, addresses, relationships and social security numbers on an attached sheet. THIRD PARTY INFORMATION Check types of coverage the patient is eligible for: Blue Cross/Blue Shield Medicaid Commercial Insurance Veteran's Carrier SSI Medicare Other Have these sources been billed to the full extent possible? YES NO If no, patient is not eligible for reduced rate. PART A Gross Income (Enumerate in Part B) Total Exceptional Expenses (Enumerate in Part C) Change in Income (Describe circumstances and proof in Part D) Liquid Assets (Enumerate in Part E) TOTAL Adjusted Annual Income Number of Dependents $ $ $ $ $ Locate amount individual responsible for ina givencalendar month on the "Financial Responsibility Table". Individual responsible for a maximum of $ in a given month. Using the "Annual Maximum Table" calculate the maximum amount the individual will be responsible for paying in any given twelve month period: % X $ = $ PART B WAGES NAME OF EMPLOYERS ADDRESSES ANNUAL INCOME PATIENT FINANCIALLY RESPONSIBLE INDIVIDUAL #1 FINANCIALLY RESPONSIBLE INDIVIDUAL #2 UNEARNED INCOME SOURCE AMOUNT PATIENT FINANCIALLY RESPONSIBLE INDIVIDUAL #1 FINANCIALLY RESPONSIBLE INDIVIDUAL #2 TOTAL INCOME PART C - Exceptional Expenses. In the space below, enumerate exceptional expenses: Expense Amount TOTAL $ PART D ­ Change in income. Describe reason for change in income and proof of such change. Include extraordinary sources of income. PART E - LIQUID ASSETS Cash Bank Deposits Securities TOTAL List names of banks funds held in: $ $ $ $ Signature I hereby attest, under penalties of perjury, that to the best of my knowledge the above information is correct. Signature I, , understand that I am responsible for contributing $ per month to my health care but no more than $ per year. If I do not fulfill this responsibility I understand that my bill will be sent to the Attorney General of the Commonwealth of Massachusetts for appropriate action. I further attest that I have been advised and understand the purposes and usesofthisinformation(listed onattached sheet) and therefore consent to this information being held by the Department of Public Health. Signature Patient or Financially Responsible Individual Date Signature Patient or Financially Responsible Individual Treasurer's Initials Signature of Interviewing Individual PART F - Was the patient denied on assessment? If so, state reasons for denial. PART G Was review asked for? YES NO Was hearing requested? YES NO What was the result: NON-TEXT PAGE