New Haven Notice of Financial Responsibility

    Thank you for choosing New Haven Youth and Family Services to help meet your needs.  The purpose of this document is to inform the parent or legal guardian of your financial responsibilities concerning your son’s care at New Haven and some of the conditions of placement at New Haven.

    New Haven provides care to you son according to all applicable laws, regulations, rules, standards, and contractual agreements.  One of the State of California regulations that applies to residential programs such as New Haven is Title XXII.  The full text of Title XXII can be found at http://www.dss.cahwnet.gov/ord/PG295.htm

    While your son is in care at New Haven, the parent or legal guardian is financially responsible for all medical care, including physical health, dental health, and eye health – including, but not limited to:  prescribed medications; physical, dental, eye examinations; prescribed treatments, services, and equipment; and all costs of hospitalizations due to illness, injury, or requited emergency psychiatric cares.

    The parent or legal guardian is also financially responsible for these mandated medical services:

    1. The State of California requires that a physical examination, meeting the standards of Title XXII, be completed and documented within the first 30 days of care in our facility.
    2. New Haven must ensure and document that each youth in our care receives an annual physical
    3. New Haven must ensure and document that each youth in our care receives a dental examination every 6 months.

    New Haven’s Medical Services Unit shall make arrangements for and transport your son to and from the medical offices for the services listed in 1 – 3 above with a provider local to New Haven (typically within 10 miles of our facilities).

    If your child is covered under health insurance, it is the responsibility of the parent or legal guardian to ensure that insurance coverage is extended to one of our local providers.  If the insurance is not transferred within the first 21 days of services at New Haven, the parent or legal guardian will be billed for health services and the parent or legal guardian shall be responsible for all direct billing of health services.

    If your child is not covered under health insurance or if your youth’s health insurance is canceled or refuses to pay for mandated health services, the parent or legal guardian will be billed for health services and the parent or legal guardian shall be responsible for all direct billing of health services.

    Name of Youth: _______________________________________

    Name(s) of Parent(s) or Legal Guardians Financially Responsible

    for Health Services:  ____________________________________

    Address: ________________________________________________

    Phone Number: __________________________________

    Health Insurance Information for Youth:

    Name of Insurance Company: _________________________________

    Insurance Company

    Customer Service Phone Number: ______________________________

    Name of Primary Insured: _____________________________________

    Group Number: ________________________

    Policy Number: ______________________

     

    By signing below I affirm that I understand and agree to comply with all terms and conditions specified in this notice:

     

    Parent or Legal Guardian Signature/Date ___________________________