Form Aap 6l - Adoption Assistance Program - Negotiated Benefit Amount And Approval
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8STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Adoption Assistance Program
Negotiated Benefit Amount And Approval
Initial
Reassessment
Part A
Adoptive Parent’s Name(s):
Child’s Adoptive Name: ___________________________________ DOB:
Financially Responsible County: _______________ Host County:
Medi-Cal Only
Deferred Agreement
Specialized Care Increment (SCI) Rate:
Financially Responsible County
Host County
Age-related state-approved foster family home rate (basic rate): $ ________ SCI: $ ________
Dual Agency Child Dual Agency Rate: $ ________ Supplemental Rate: $ ________
Out-of-Home Placement
AAP Rate Classification Level (RCL): ________
State Approved Facility Rate: $ ________
Another Entity
Basic Rate: $ ________ Share of Cost: $ ________
Wraparound
RCL: ________ RCL Rate: $ ________
AAP 6L (1/17)
PAGE 1 OF 8
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Parent category: Legal