Behavioral Health and Recovery Services - Financial Responsibility Form

Behavioral Health and Recovery Services
Financial Responsibility Form

Client #

Facility Program

Client Name*

First NameMiddle InitialClient Last Name

Client Address

Street Address

Apartment

CityState / Province

Postal / Zip Code

Home Phone

Please enter a valid phone number in the format (000) 000-0000

Cell Phone

Please enter a valid phone number in the format (000) 000-0000

Date of Birth

MonthDayYear

Date of Birth for PDF

Date

Social Security Number

Driver License #

Assigned sex at birth

MaleFemaleOther

Employment Status*

EmployedUnemployedRetiredOther

Person Financially Responsible for Client*

SelfRep Payee/ConservatorOther

If Other, Name

Date of Birth

MonthDayYear

Relationship

Address of Person Financially Responsible

Street Address

Apartment

CityState / Province

Postal / Zip Code

Home Phone

Please enter a valid phone number in the format (000) 000-0000

Cell Phone

Please enter a valid phone number in the format (000) 000-0000

Monthly Family Gross Income (Including SSI, Disability, Unemployment, etc.)

Number of Dependents (including Self)

Monthly Income

Self

Parent/Spouse

Other

Monthly Income

	Amount ($)
Self
Parent/Spouse
Other
Total Income

Total Assets

Checking

Savings

Other

Total Assets

	Amount ($)
Checking
Savings
Other
Total Assets

Monthly Expenses

Court Ordered

Child Care

Dependent Support Payments

Retirement Payments

Medical

Monthly Expenses

	Amount ($)
Court Ordered
Child Care
Dependent Support Payments
Retirement Payments
Medical
Total Monthly Expenses

Total Income

Total Assets

Total Expenses

Health Insurance Information (Must be completed if client has health insurance)

Medi Cal/CMSP #

Medicare #

Health Insurance Information

	Primary Carrier	Secondary Carrier
Insurance Company
ID#
Group #
Effective Date
Insured Name
Insured DOB
Claim Address

Check to authorize payment and type in Client Signature*

I hereby authorize payment directly to County of Marin Behavioral Health and Recovery Services for all applicable insurance benefits which I am entitled. Authorization to bill will be effective from the first date of service rendered by BHRS. I hereby authorize BHRS to furnish any and all information contained in, or disclosed by the records of BHRS to respective insurance companies to the extent necessary to satisfy claims for reimbursement of services rendered. I understand that I am financially responsible for all charges including those not fully reimbursed by my insurance carrier within the limits determined by the County of Marin in examining my ability to pay. If I refuse to provide income information, I will be charged for the full cost of my services. A photocopy of this document is to be considered as valid as an original.

Client Signature*

Signature Date*

MonthDayYear

Signature Date for PDF

Date

Authorized Representative

Relationship

Billing Staff

Annual Liability ($)

No spaces allowed

Annual Liability Date

MonthDayYear

Annual Liability Date for PDF

Date