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Board of Health P & P Manual, Section I Policy E, Attachment B Updated 11/2014, 4/2017 S:\MANAGERS WORKING FILES\BOH\AGENDAS & ABSTRACTS\2017 Agenda & Abstracts\August 2017\VI.E. I.E. Attachment B - Eligibility Finan Resp (7-2017).docx DETERMINATION OF ELIGIBILITY FOR CLINICAL SERVICES The Orange County Health Department, following approved policy and procedures, has determined that _____________________ (Client Name) is eligible for [circle] Medical / Dental services and will be charged _______ percent (%) of the total fees, based on the number of people living in the home and the total amount of gross income in the home. STATEMENT OF FINANCIAL RESPONSIBILITY _______ I understand that I am responsible for all fees involved in receiving services at the Orange County Health Department (as stated above) _______ I understand that I am required to provide income verification to be eligible for the sliding fee scale. If I do not provide income verification in the next 3010 business days or less(by _______________), any services I receive that are not covered by insurance, with the exception of Family Planning services, will be billed at 100% on the sliding fee scale. _______ I understand that if I report that I am pending Medicaid eligibility, but I do not follow- through with the Medicaid application or do not receive coverage, I will be responsible for all charges based on the sliding fee scale determination. _______ I understand that payment is due at the time services are provided. I further understand that, if circumstances do not allow full payment on the day of service, a payment plan will be established. _______ I understand I will receive a statement and an overdue notice for balances older than 30 days that are equal to or greater than $50.00. I also understand that if I do not submit payment in full or honor a monthly payment plan within 30 days of that statement date; my account will be sent to the Orange County attorney for debt setoff. _______ I understand that if I do not make a “good faith” effort to pay on any past bills due, future services may be limited or denied. However, emergency services will not be denied. I understand I must notify the clinic as soon as possible if I cannot keep my appointment. Medical Clinics: 919-245-2400 Dental Clinic: 919-245-2435 __________________________________________________ ________________________ Signature of Client/Responsible Party Date __________________________________________________ ________________________ Signature of Interpreter Date __________________________________________________ ________________________ Signature of OCHD Employee Date Initial Initial Initial Initial Initial Initial