BOH Agenda 082620 - Laserfiche WebLink

Browse Search

Board of Health P&P Manual, Section I Policy E,Attachment B 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 Initial County Health Department(as stated above) I understand that I am required to provide income verification to be eligible for the Initial sliding fee scale. If I do not provide income verification in the next 10 business days (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- Initial 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 Initial 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 Initial days that are equal to or greater than$50.00. 1 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 Initial 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 Updated 11/2014,4/2017 S:\MANAGERS WORKING FILES\BOH\Policies and Procedures\BOH Policy Manual\Current Policy Manual\I.E.Attachment B-Eligibility&Finan Resp(4-2017)docx.docx