La. Admin. Code tit. 48 § V-5903
CSHS Medical Category | Treatment Phase | Number 1=High Cost - Active treatment/Medically Fragile/Surgery 5=Moderate Cost-Routine treatment/ Medically stable 10=Least Cost-Follow-up/Observation |
1. Arthritis | Active treatment/Medically fragile/surgery Active treatment/Medically stable Inactive - Remission | 1 5 10 |
2. Audiology | Diagnosis Testing Audiology Appliances and Molds Follow-up | 5 5 10 |
3. Cardiology | Surgery/Hospitalization Diagnostic Tests(inpatient) Active treatment/Medically stable Observation (includes routine clinic test) | 1 1 5 10 |
4. Cleft Palate And/Or Lip | Surgery/Hospitalization Orthodontic Treatment Routine treatment/Medically stable Follow-up/Observation (No surgery or orthodontia anticipated) | 1 1 5 10 |
5. Cystic Fibrosis | Treatment | 1 |
6. Nephrology | Active treatment/Medically fragile Routine treatment/medically stable Inactive -Remission | 1 5 10 |
7. Neurology | Hospitalization/Active treatment/Medically fragile Routine treatment/Medically stable Inactive - Remission | 1 5 10 |
8. Neurosurgery | Surgery/Hospitalization Active treatment/Medically fragile Routine treatment /Medically stable Follow-up (No surgery or therapy anticipated) | 1 1 5 10 |
9. Ophthalmology | Surgery/Hospitalization Active treatment Follow-up (No medication or treatment anticipated) | 1 5 10 |
10. Orthopedic Amputee Cerebral Palsy Hand Scoliosis Spinal Cord | Surgery/Hospitalization Active treatment/Wheelchair/Bracing Active treatment (No bracing) Follow-up (No surgery or treatment anticipated) | 1 1 5 10 |
11. Otology | Surgery/Hospitalization Active treatment Follow-up (No surgery or treatment anticipated) | 1 5 10 |
12. Reconstructive Surgery (Other Than Cleft Lip And Palate) | Surgery/Hospitalization Active treatment/Therapy Follow-up (No surgery or therapy anticipated) | 1 5 10 |
16. Urology | Surgery/Hospitalization Active treatment /Medically fragile Active treatment /Medically stable Follow-up (No surgery or hospitalization anticipated) | 1 1 5 10 |
If a child has multiple conditions in mixed levels of activity, the lowest value shall be chosen. If two or more children in a family are applying for services, each child will be considered separately for medical eligibility. | ||
PATIENT'S NAME:__________________ PID Number ___________
DOB:__________________
CHILDREN'S SPECIAL HEALTH SERVICES
FAMILY INCOME AND RESOURCE WORKSHEET
Please fill out this form. You are responsible for its accuracy. A social services worker or Eligibility Determination Examiner will review the form with you and determine your eligibility for CSHS. CSHS requires eligibility to be determined when your child is a new patient, on an annual basis and when a major expenditure is anticipated.
FAMILY INCOME
Person(s) Employed Yes No Total Monthly For CSHS Staff
Gross Income Use Only
Father _____ _____ $_____________ ______________
Mother _____ _____ $_____________ ______________
Other _____ _____ $_____________ ______________
Sources of Other Income:
A.F.D.C.____ _____ _____________ ______________
S.S.I. ____ _____ _____________ ______________
Refugee Cash Assistance
____ _____ _____________ ______________
Social Security
____ _____ _____________ ______________
Veterans Benefits
____ _____ _____________ ______________
Pension or Retirement
____ _____ _____________ ______________
Unemployment Benefits
____ _____ _____________ ______________
Workman's Compensation
____ _____ _____________ ______________
Child Support ____ _____ _____________ ______________
Military Family Allotment
____ _____ _____________ ______________
Alimony ____ _____ _____________ ______________
Interest and Dividends from ______________
Savings, Stocks, Bonds, etc.
____ _____ _____________ ______________
TOTAL FAMILY INCOME $_____________ $_____________
Less Deductions:
Child support payments for children
Living outside of your home $_____________ $_____________
Yearly medical insurance premiums _____________ _____________
Medical payments other than insurance
reimbursement for 12 months _____________ _____________
TOTAL DEDUCTIONS $_____________ $ ____________
-----------------------------------------------------FOR CSHS STAFF USE-------------------------------------
Total Family Income $______________________
Less Total Deductions (-)_____________________
Adjusted Family Income $______________________
Less Size of Family (-)_____________________
Plus Medical Category Number (+)_____________________
ELIGIBILITY DETERMINATION VALUE ____________________
Income Eligible Yes ______ NO_______
FAMILY RESOURCE
FOR CSHS
Savings Accounts Yes No Value or Equity STAFF USE ONLY
Individual ____ _____ $_____________ ________________
Joint ____ _____ _____________ ________________
Both ____ _____ _____________ ________________
________________
Promissory Note ____ _____ _____________ ________________
________________
Time Deposit ________________
(i.e., certificate of deposit)
____ _____ _____________ ____ _______________________
Family-held Mortgage ____ _____ ___________ ___________
Mutual Fund Shares ____ _____ _____________ ___________
Municipal, Corporate and/or _________________
Government Bonds/stocks ____ _____ ___________ ___________
Property (other than home) ____ ____ _________ __________
Share in Estate(undivided estate) _________________
(when in control of family) ____ _____ ________ _________
Trust (have access to trust) ____ _____ __________ _________
Mineral Rights ____ _____ ____________ _____________
Vehicles (other than 2 family cars) ___ ____ _______ _______
(Description include boats, campers, motor homes, motorcycles, 4 wheelers)
Settlements (structured or lump sum) or winnings
____ _____ _____________ _________________
Crops in Storage ____ _____ ____________ ______________
IRA (when other retirement benefits are available)
____ _____ ____________ _________________
Keogh (same as above) ____ _____ __________ _____________
-------------------------FOR CSHS STAFF USE ONLY------------------------
Total Family Resources $ ________________________
Less Resource Allowance (-)
Total Adjusted Resource $_________________________
Resource Eligible Yes ______ No_______
The information I have given is true and correct to the best of my knowledge. I understand that verification of income and/or resources may be requested.
I understand that my application will be reviewed for eligibility purposes and that I have the right to appeal if my child is denied acceptance or if I feel my civil rights have been violated.
If verification of family income and resources are requested, the requested items must be returned within fifteen (15) days of this date to the CSHS Regional Office or the case will be closed and services terminated.
I agree to notify the CSHS Regional Office of any lawsuit filed on behalf of the applicant pertaining to his disability and for which the CSHS is providing medical services. Failure to sign necessary documents (i.e., SSI, Medical Needy, Medicaid, etc,) will cause the patient to be discharged from CSHS.
_____________________________________________________
Parent/Applicant or Appropriate Representative Date Relationship
_____________________________________________________
Witness Date
________________________________________________________
CSHS Eligible ______ CSHS Ineligible _______ Pending _______
______________________________________________________ ___
Reviewed by Title Date
ASSIGNMENT OF INSURANCE BENEFITS
NAME OF INSURANCE COMPANY:
ADDRESS OF INSURANCE COMPANY:
NAME OF INSURED:
ADDRESS OF INSURED:
POLICY Number:
I/We,_________________________________________________, am/are the parent(s) and/or guardian(s) of
_______________________________, who has been enrolled in CHILDREN'S SPECIAL HEALTH SERVICES of the Office of Public Health of the Department of Health and Hospitals.
I/We hereby authorize and direct CHILDREN'S SPECIAL HEALTH SERVICES to prepare and submit claims for the
medical or hospital expense incurred by _________________ to the captioned insurance company.
I/We hereby authorize and direct the said insurance company to honor and recognized this instrument wherein I/we assign, transfer, set over and deliver to the said CHILDREN'S SPECIAL HEALTH SERVICES of the Office of Public Health of the Department of Health and Hospitals, as assignee herein, all money, checks, drafts or payments now due and payable to me/us, and to become due and payable to me/us, for the medical care and treatment of
_________________________, under the terms and conditions of the above numbered insurance policy. The insurance company is further directed to forward all such payment directly to CHILDREN'S SPECIAL HEALTH SERVICES at the address indicated on the papers submitting the claim(s).
In witness whereof I/we have executed this assignment at _____________, the __________day of________________, _______.
WITNESSED BY:
_________________________ ___________________________
Signature of insured
_________________________ ___________________________
NOTE: Two witnesses are required who are age 21 or older.
INTERVENTION AND SUBROGATION AGREEMENT
STATE OF LOUISIANA PARISH OF ________________________
BEFORE ME,
a Notary Public, duly commissioned and qualified, in and for the Parish of___________________,
State of Louisiana, on this ____________________day of _______________, ____ in the presence of the witnesses hereinafter named and undersigned, personally came and appeared:
WHO DECLARED that they are the parents or guardians of ____________________, who has received and/or is now under medical treatment and care provided by Children's Special Health Services of the Office of Public Health of the Department of Health and Hospitals, as the result of accidental injuries sustained by the said child on or about _______________________.
AND THE SAID APPEARERS FURTHER DECLARED that they hereby assign transfer, set over and deliver unto Children's Special Health Services of the Office of Public Health of the Department of Health and Hospitals, its successors and assigns, to its proper use and benefit forever, any and all sum or sums now due or owing said assignors, and all claims, demands and cause or causes of action of whatever kind and nature which said assignors had or now have or may have against __________________________________, arising out of or as a result of the accidental injuries sustained by the said child on or about_____________.
This assignment, however, is EXPRESSLY LIMITED to the value of the said medical treatment and care provided, furnished or obtained by Children's Special Health Services of the Office of Public Health of the Department of Health and Hospitals on behalf of the said child as the result of accidental injuries sustained by the said child on or about_____________________.
Nothing herein shall prevent the said appearers from presenting claims or claims, if any they had or have or may have against ______________________ for damages in an amount in excess of the assigned value of medical treatment and care described and referred to hereinabove; however, the said appearers do hereby further agree, consent and promise to duly notify Children's Special Health Services of the Office of Public Health of the Department of Health and Hospitals of any legal steps, if any, they may have taken or are now taking or may take against the said ____________________________, as a result of the accidental injuries sustained by the said child as described and referred to hereinabove.
APPEARERS FURTHER hereby authorize and direct and empower said Children's Special Health Services of the Office of Public Health of the Department of Health and Hospitals to intervene in any legal cause of action of proceeding that appearers may have taken or are now taking or may take against _________________________ as a result of the accidental injuries sustained by the said child as described and referred to hereinabove, such intervention-power EXPRESSLY LIMITED to the value of the said medical care and treatment.
THUS DONE AND PASSED AS AN AUTHENTIC ACT BEFORE ME,__________________, a Notary Public, duly commissioned and qualified in and for the Parish of ___________________,
State of Louisiana in the presence of the undersigned witnesses and sworn to by the said appearers ________________and______________this_____day of _________, _____.
APPEARERS:
_________________________
_________________________
WITNESSES: (address)_________________________
___ ________________________(address)______________________
_____________________________ __________________________
NOTARY PUBLIC
and (affix seal)
_____________________________ (address)___________________
(address)_______________ _______________________
_____________________________ __________________________
DHH/Secretary
La. Admin. Code tit. 48, § V-5903