Financial Information Form - Sacramento County Division Of Behavioral Health Services Page 2

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INSTRUCTIONS:

Complete the entire form as it pertains to the person receiving behavioral health services.

DEMOGRAPHICS SECTION

①

Person receiving services:

Enter the name, birthdate, Social Security Number, phone numbers and email address of the person to receive

behavioral health services

RECORD OF FINANCIAL DATA SECTION

②

Employer:

Enter the employer name and address. Indicate in the appropriate box whether the position is full- or part-time.

③

Medi-Cal:

Indicate whether the person receiving services is enrolled in Medi-Cal; enter the Medi-Cal ID number as shown on their Medi-Cal card.

④

Medicare:

Indicate whether the person receiving services is enrolled in Medicare; enter the Medicare ID number as shown on their Medicare card.

⑤

Other Health Insurance:

Indicate whether the person receiving services has a health insurance policy through an employer or purchased privately

such as Kaiser, Dignity Health, etc. If so, enter:

The health plan or insurance carrier name

•

The policy and group number

•

The primary subscriber’s name and birth date. If you have insurance through your parent(s), spouse, or registered domestic partner, the

•

parent/spouse/domestic partner would be the primary subscriber.

The relationship to the person receiving services. If the person receiving services is the primary subscriber, check the box indicating ‘Self’.

•

⑥

Secondary Other Health Insurance:

Indicate whether the person receiving services has a

second

health insurance policy through an employer

or purchased privately such as Kaiser, Dignity Health, etc. If so, enter:

The health plan or insurance carrier name

•

The policy and group number

•

The primary subscriber’s name and birth date. If you have insurance through your parent(s), spouse, or registered domestic partner, the

•

parent/spouse/domestic partner would be the primary subscriber.

The relationship to the person receiving services. If the person receiving services is the primary subscriber, check the box indicating ‘Self’

•

AGREEMENT TO PAY SECTION

– only check ONE box in this section.

⑦

Check this box if the person receiving services has full-scope Medi-Cal (Medi-Cal with no share-of-cost).

⑧

Check this box if you have Medi-Cal with a share-of-cost or if you have Medicare or other health insurance with a monthly copay requirement. By

checking this box, you agree to pay this cost.

⑨

Check this box if you’ve made arrangements to pay an UMDAP amount.

UMDAP Year Start Date is the first day of the month that the UMDAP amount was created

•

Example: if services began on July 25, 20XX; the year start date would be July 1

, 20XX

Annual UMDAP liability is the dollar amount a customer is responsible to pay for one year of services per their UMDAP agreement

•

⑩

Check this box if you choose not to provide financial information. In doing so, you agree to be responsible to pay for any services provided to you

through the Mental Health Plan.

⑪

Enter the name of the person who is financially or legally responsible for the person receiving services. If you are both the person receiving services and

the financially responsible party, write your name and enter ‘self’ in the Relationship box. Enter the address and phone number(s) for the financially

responsible party/legal representative. Have the financially responsible person sign and date on the appropriate lines. The ‘Signature of witness’ is

reserved for the provider representative.

DEFINITIONS:

ABN: A notice alerting those who have Medicare that services provided may not be covered by Medicare

Copay: An individual’s payment responsibility amount for a covered service, paid when the individual receives service

EPO: Exclusive Provider Organization

ERISA: Employee Retirement Income Security Act

Full-scope Medi-Cal: Medi-Cal coverage with no share-of-cost, where all covered services are free to the recipient

HMO: Health Maintenance Organization

Indemnity insurance: An insurance policy that aims to protect business owners and employees when they are found to be at fault for a specific event such

as a misjudgment

PPO: Preferred Provider Organization

Share of Cost: the monthly dollar amount a Medi-Cal recipient pays before Medi-Cal aid is applied

UMDAP: Uniform Method of Determining Ability to Pay

Revised 5/11/2016