Financial Information Form - Sacramento County Division Of Behavioral Health Services
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1
2Sacramento County
Division of Behavioral Health Services
FINANCIAL INFORMATION FORM
①
Person receiving services:
Last Name
First Name
M.I.
GRAYED OUT AREAS FOR PROVIDER USE ONLY:
Eligibility Verified?
☐ Yes
☐ No
Maiden or Other Name (if any)
Birthdate
SSN
Avatar ID#:
Daytime Phone Number
Secondary Phone Number
Email Address
RECORD OF FINANCIAL DATA
②Employer Business Name
☐ Full Time
☐ Part Time
Employer Address:
Number
Street
City
State
Zip Code
...
③Does the person receiving services
☐ Yes
☐ No
Medi-Cal ID:
Eligibility Verified?
☐ Yes
☐ No
have Medi-Cal?
④Does the person receiving services
☐ Yes
☐ No
Medicare HIC:
Eligibility Verified?
☐ Yes
☐ No
have Medicare?
Do services require an ABN (Advanced Beneficiary Notice)?
☐ Yes
☐ No
Is completed ABN signed, dated and on file?
☐ Yes
☐ No
Health plan or insurance carrier name
Policy/Group Number
⑤Does the person receiving services
Yes
☐ No
☐
have other health insurance?
If yes,
Policy Verified?
(HMO, PPO, EPO, Indemnity, ERISA, etc.)
ATTACH COPY OF CARDS
Primary Subscriber’s Name
Date of Birth
Relationship to person receiving services:
Employee ID
☐ Yes
☐ No
☐ Self
☐ Other:
☐ Yes
☐ No
Health plan or insurance carrier name
Policy/Group Number
⑥Does the person receiving services
have a secondary other health insurance?
If yes,
Policy Verified?
(HMO, PPO, EPO, Indemnity, ERISA, etc.)
ATTACH COPY OF CARDS
Primary Subscriber’s Name
Date of Birth
Relationship to person receiving services:
Employee ID
☐ Yes
☐ No
☐ Other:
☐ Self
AGREEMENT TO PAY
(Check Only ONE Box)
⑦
☐ I (the person receiving services) have full-scope Medi-Cal
• I agree that if I no longer qualify for or do not have Medi-Cal or other health insurance, I will be reevaluated by my provider to determine
eligibility and potential financial obligation.
☐ I will pay the monthly share-of-cost/copay responsibility for services provided
⑧
UMDAP year start date:
⑨ ☐
I will pay an annual UMDAP responsibility for services provided as agreed upon with my provider
Annual UMDAP liability:
⑩ ☐
I refuse to provide financial information and I have been notified that I will be charged in full for services received
•
I agree to provide information to Sacramento County about other health insurance that I may have.
•
I agree to tell my service provider within 30 days if there are any changes in my financial situation. I understand that any of these
changes may also change the amount I need to pay each year.
•
By signing this form I agree that the information provided is complete and truthful. If not, it may result in my having to pay for the full
cost of services received.
I hereby authorize insurance benefits for services received at a Sacramento County mental health facility or authorized contracted provider to b
directly to the County of Sacramento.
⑪ Financially Responsible Party or Legal Representative: Name
Relationship
Daytime Phone Number
Address:
Number
Street
City
State
Zip Code
Secondary Phone Number
...
___________________________
___________
___________________________
___________
Signature of responsible party
Date
Signature of Provider Representative
Date
Revised 5/11/2016
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