<p>Client Number: Date Completed: Completed By: </p><p>PAYOR OF LAST RESORT/FEE FOR SERVICE SCREENING TOOL</p><p>PART 1: IDENTIFYING BILLABLE SOURCES * Case Managers must support and assist clients in applying for ALL potential sources of assistance</p><p>Third Party Payors for Medical Services: Client Potentially Why or Has: Payor Eligible? Why Not? Applied? Approved? Notes Employer-Based Yes Yes Yes Insurance No No No</p><p>Yes Yes Yes Medicare* No No No</p><p>Yes Yes Yes Medicaid* No No No</p><p>County Indigent Yes Yes Yes Health Care No No No</p><p>Yes Yes Yes CHIP No No No</p><p>Yes Yes Yes VA Benefits No No No Other: Yes Yes Yes No No No Other: Yes Yes Yes No No No</p><p>Other assistance programs: Client Potentially Why or Enrolled: Program: Eligible? Why Not? Applied? Approved? Notes Yes Yes Yes THMP/ADAP No No No</p><p>Yes Yes Yes WIC No No No</p><p>Medicare Yes Yes Yes Part D No No No</p><p>Yes Yes Yes Food Stamps* No No No</p><p>Pharmaceutical Yes Yes Yes Assistance No No No Other: Yes Yes Yes No No No Other: Yes Yes Yes No No No * Eligibility for programs marked with an asterisk above can be identified through www.yourtexasbenefits.com PART 2: FINANCIAL SCREENING</p><p>Income determination for Individual or Family (family size: )</p><p>Income Source: Gross Amount Per Year: Paid To (Name): Documentation:</p><p>Total Gross Annual Income: $</p><p>PART 3: FEE DETERMINATION</p><p>Client’s FPL Calculation Total Allowable Individual/Family Annual Gross Income Income Is: (for family size of ) Annual Charges No charges Equal to or below the official poverty line permitted 5% or less of gross 101 to 200 percent of the official poverty line income 7% or less of gross 201 to 300 percent of the official poverty line income More than 300 percent of the official poverty 10% or less of gross line income</p><p>Client’s Maximum Allowable Annual Charge: $</p><p>NO FEE WILL BE CHARGED Client has a billable source for medical services OR client’s individual/family gross income is equal to or below the official poverty line</p><p>CLIENT WILL BE CHARGED A FEE OF $ Client has no billable source for medical services AND client’s individual/family gross income is 101% or greater of the official poverty line</p>