NAMI MAINE RESPITE CARE APPLICATION

Families must meet the following eligibility criteria:

  • The child must be age 18 or younger.
  • The child must have a documented mental, emotional, behavioral, or developmental diagnosis,
  • The child must be living with you

Family Information:

___ Parent / ___ Guardian Name: ______

Mailing Address: ______

City / Town: ______Zip Code: ______

Telephone: ______

Email Address: ______

Primary language:

___ English ___ French ___ Spanish ___ Other ___ Decline to Answer

Race/Ethnicity:

___ White (non-Hispanic/non-Latino) ___ Hispanic/Latino

___ Native American ___ African

___ Black/African ___ American Asian (non-Pacific Islander)

___ Pacific Islander ___ Multi-ethnic/multi-racial

___ Other ___Decline to Answer

Determination of FeePercentage

for Families Receiving Children’s Respite Services

1. Adjusted Gross Income (AGI) – previous years federal tax return______

From IRS Form 1040, Line 34: Form 1040A, Line 21: or Form 1040EZ

Line 4: or total income per month X 12.______

2. Deduction for more than one child receiving services from the

Department of Health and Human Services – Deduct $3,050 for

each additional child.______

3. Un-reimbursed Health Care Expanses

Defined by Internal Revenue Services policies

a. Health insurance Premiums

Excluding any premiums deducted from wages ______

b. Doctors ______

c. Hospitals ______

d. Medicine ______

e. Transportation ______

f. Fees assessed for other DHHS services ______

(i.e. case management, Katy Beckett)

g. Other – Please specify (extra Respite out ______

Of pocket, special equipment)

TOTAL Un-reimbursed Health Care Expenses (a-g)______

4. 7.5 percent of Line 1 (AGI) – Multiply Line 1 by .075)______

5. Health Care Cost Exemption: If Line 3 exceeds 4, enter difference______

6. Income to Determine Sliding Fee Percent (Line 1 minus Line 2 and 5)______

7. Number of Individuals Residing in Household (adults and minors)______

Client Name: (Printed) ______

I understand I am required to give complete and truthful information. I understand that false statements made on this form are punishable as a crime.

Completed By: ______

Parent(s)/Guardian(s)/Responsible for Care of Child: ______

Date: ______

FOR AGENCY USE ONLY

Fee % from Determination Schedule: ______

Completed by: ______Date: ______

THIS FORM IS REQUIRED BY THE STATE OF MAINE

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DHHS Children’s Behavioral Health Services - Sliding Fee Schedule as Mandated by 34-B MRSA sec1208 ss 8

Applicable to services funded through CBHS state grant funds for Respite, Outpatient and Case Management

Household Income Range According to Family Size:

Federal Poverty Level / Fee as % of Cost of Service / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9
0-249% / No Fee / 0 to $34,224 / 0 to $42,924 / 0 to $51,624 / 0 to $60,324 / 0 to $69,024 / 0 to $77,724 / 0 to $86,424 / 0 to $95,124
250-
317% / 25% / $34,225 to $43,534 / $42,925 to $54,600 / $51,625 to $65,666 / $60,325 to $76,733 / $69,025 to $87,799 / $77,725 to $98,866 / $86,425 to $109,932 / $95,125 to $120,998
318-
384% / 50% / $43,535 to $52,706 / $54,601 to $66,104 / $65,667 to $79,502 / $76,734 to $92,900 / $87,800 to $106,298 / $98,867 to $119,696 / $109,933 to $133,094 / $120,999 to $146,492
385-
450% / 75% / $52,707 to $61,741 / $66,105 to $77,436 / $79,503 to $93,131 / $92,901 to $108,826 / $106,299 to $124,521 / $119,697 to $140,215 / $133,095 to $155,910 / $146,493 to $171,605
451%+ / 100% / $61,742+ / $77,437+ / $93,132+ / $108,827+ / $124,522+ / $140,216+ / $155,911+ / $171,606+

Developed in collaboration with the Bureau of Family Independence calculated from Federal Poverty Levels effective February 2007

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