Form Aap 6 - Adoption Assistance Program - Negotiated Benefit Amount And Approval
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5State of California – Health and Human Services Agency
California Department of Social Services
ADOPTION ASSISTANCE PROGRAM
Initial Negotiation
NEGOTIATED BENEFIT AMOUNT AND APPROVAL
Subsequent Renegotiation
Part A
Prospective or Adoptive Parents Name(s): _____________________________________________________
Child’s Adoptive Name: ____________________________________________ DOB: __________________
Financially Responsible County: _______________ Host County: _______________ Host State: ________
Medi-Cal Only
Deferred Agreement
AAP Basic Rate: $ ________
Specialized Care Increment (SCI) Rate: $ ________
Financially Responsible County
Host County
Host State
Dual Agency Child Dual Agency Rate: $ ________ Supplemental Rate: $ ________
Out-of-Home Placement
To be paid by AAP:
Facility Name: ___________________________ Facility Rate: ___________
One check to be issued to the facility
One check to be issued to the adoptive parent(s) who will pay the facility
Two checks to be issued:
$_________ to be paid to the facility
$_________ to be paid to the adoptive parent(s)
To be paid by another entity Basic Rate: $ ________
Share of Cost : $ ________
Wraparound
To be paid by AAP: Provider Name: ______________________________________ Rate: ___________
One check to be issued to the provider
One check to be issued to the adoptive parent(s) who will pay the provider
Two checks to be issued:
$_________ to be paid to the provider
$_________ to be paid to the adoptive parent(s)
Child’s Special Needs and Underlying Problem or Condition: _______________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
AAP 6 (1/18)
Page 1 of 5
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