Minor Consent Forms by gli17247

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									Data Entry Sheet - FY 2008-09
ODF Group - Perinatal

                          County Name
                          Contractor/Provider Name
                          Contract Period
                          4-digit DMC Number
                          6-digit CADDS Provider Number



                                                          COST INFORMATION
    Private Pay                  Drug Medi-Cal               NNA/Public Funded
                                                                                   Personnel Services
                                                                                   Salary and Wages
                                                                                   Employee Benefits
                                                                                   Direct Services
                                                                                   Clothing and Personal Supplies
                                                                                   Food
                                                                                   Laundry Services and Supplies
                                                                                   Pharmaceutical
                                                                                   Other
                                                                                   Equipment, Materials and Supplies
                                                                                   Depreciation - Equipment
                                                                                   Maintenance - Equipment
                                                                                   Medical, Dental and Laboratory Supplies
                                                                                   Membership Dues
                                                                                   Rent and Lease Equipment
                                                                                   Small Tools and Instruments
                                                                                   Training
                                                                                   Other
                                                                                   Operating Expenses
                                                                                   Communications
                                                                                   Depreciation - Structures and Improvements
                                                                                   Household Expenses
                                                                                   Insurance
                                                                                   Interest Expense
                                                                                   Lease Property Maintenance, Structures, Improvements and Grounds
                                                                                   Maintenance - Structures, Improvements, and Grounds
                                                                                   Miscellaneous Expense
                                                                                   Office Expense
                                                                                   Publications and Legal Notices
                                                                                   Rents & Leases - Land, Structure, and Improvements
                                                                                   Taxes and Licenses
                                                                                   Drug Screening and Other Testing
                                                                                   Utilities
                                                                                   Other
                                                                                   Professional and Special Services
                                                                                   Professional and Special Services
                                                                                   Transportation
                                                                                   Transportation
                                                                                   Travel
                                                                                   Gas, Oil, & Maintenance - Vehicles
                                                                                   Rents & Leases - Vehicles
                                                                                   Depreciation - Vehicles
                                                                                   Other Costs
                                                                                   Indirect Costs
                                                                                   DMC County Administration
                      0                             0                            0 Total Costs
                                                                                   Direct Costs (only if both NNA and DMC funding is identified)




    1cc03e4c-8dcc-46e3-8c15-e207a401cbfd.xls - Data Entry Sheet                                                                         1 of 7
                                                FEES, INSURANCE, UNIT INFORMATION
         Private Pay                   Drug Medi-Cal                NNA/Public Funded
                                                                                          Participant Fees
                                                                                          Insurance, Medicare and Other Third Party

                                                                                          Individual Face to Face Visits
                                                                                          Group Face to Face Visits
                                                                                          Daycare Day (non Minor Consent)
                                                                                          Residential Day
                                                                                          Other - Minor Consent and non-Minor Consent 100% SGF
                                                           0                            0 Adjustment for DMC Denied/Unallowed Units (Negative in DMC column)
                                                                                          Group Sessions
                                                                                          Staff Hours



Drug Medi-Cal Reconciliation of Claims (Units)
                              Total Claims (Units) Submitted
                              1st Reporting Period - July through September
                              2nd Reporting Period - October through June

                               Minor Consent - July through September - 7N Aid Code
                               Minor Consent - October through June - 7N Aid Code

                               Minor Consent - July through June - non-7N Aid Code
                               Non-Minor Consent - 100% SGF July through June
                               Total Claims (Units) Denied
                               1st Reporting Period - July through September
                               2nd Reporting Period - October through June

                               Minor Consent - July through September - 7N Aid Code
                               Minor Consent - October through June - 7N Aid Code

                               Minor Consent - July through June - non-7N Aid Code
                               Non-Minor Consent - 100% SGF July through June
                               Total Claims (Units) Adjusted/Erroneous
                               1st Reporting Period - July through September
                               2nd Reporting Period - October through June

                               Minor Consent - July through September - 7N Aid Code
                               Minor Consent - October through June - 7N Aid Code

                               Minor Consent - July through June - non-7N Aid Code
                               Non-Minor Consent - 100% SGF July through June

Revenue from Drug Medi-Cal Units of Service
                         0 Revenue/Fees (Share of Costs)

DMC Prorated Rate
                              Prorated Rate
                        63.62 Statewide Maximum Allowable (SMA) Rate




         1cc03e4c-8dcc-46e3-8c15-e207a401cbfd.xls - Data Entry Sheet                                                                           2 of 7
                                               DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS
                                                      DRUG MEDI-CAL FISCAL DETAIL
                                                 REPORT OF EXPENDITURES AND REVENUES
                                                               FY 2008-09

                                                                    SUMMARY

  COUNTY                                                     0
  CONTRACTOR                                                 0                    MEDI-CAL PROV. NO.                             0
  CONTRACT PERIOD                                            0                    CADDS PROVIDER NO.                             0


    TYPE OF PROGRAM - ODF Group - Perinatal
                                                                     A                 B               C                D                E
                                                                   TOTAL             PRIVATE                        NNA/PUBLIC       TOTAL MC/
                CATEGORIES                                        PROGRAM             PAY           MEDI-CAL         FUNDED          NNA/PUBLIC
  A. PERSONNEL SERVICES                                                    0.00              0.00            0.00             0.00             0.00
  B. DIRECT SERVICES                                                       0.00              0.00            0.00             0.00             0.00
  C. EQUIPMENT MATERIALS & SUPPLIES                                        0.00              0.00            0.00             0.00             0.00
  D. OTHER OPERATING EXPENSES                                              0.00              0.00            0.00             0.00             0.00
  E. PROFESSIONAL & SPECIAL SERVICES                                       0.00              0.00            0.00             0.00             0.00
  F. TRANSPORTATION                                                        0.00              0.00            0.00             0.00             0.00
  G. INDIRECT COSTS                                                        0.00              0.00            0.00             0.00             0.00
  G1. COUNTY ADMINISTRATION                                                0.00                              0.00                              0.00
    TOTAL GROSS COSTS                                                    $0.00             $0.00           $0.00            $0.00            $0.00
    REVENUES
  H. PARTICIPANT FEES                                                      0.00                0               0                 0             0.00
  I. INSURANCE, MEDICARE, & OTHER THIRD PARTY                              0.00                0               0                 0             0.00
    NET COSTS (GROSS COSTS LESS LINES H,I)                                 0.00              0.00            0.00             0.00             0.00
    UNITS OF SERVICE
  L. INDIVIDUAL FACE TO FACE VISITS                                          0                 0               0                 0                 0
  M. GROUP FACE TO FACE VISITS                                               0                 0               0                 0                 0
  N. DAYCARE DAY                                                             0                 0               0                 0                 0
  O. RESIDENTIAL DAY                                                         0                 0               0                 0                 0
  P. OTHER (Specify) - MINOR CONSENT and Non-Minor Consent 100%
  SGF                                                                        0                 0               0                 0                 0
  SUBTOTAL                                                                  0                  0               0                 0                0
  Q1. ADJUSTMENT FOR DMC DENIED/UNALLOWABLE UNITS                            0                 0               0                 0                 0
  Q2. ADJUSTED TOTAL                                                        0                  0               0                 0                0
  R. GROUP SESSIONS                                                          0                 0               0                 0                 0
  S. STAFF HOURS (DIRECT SVCS - COUNSELING, MEDICAL, ETC.)                   0                 0                                 0                 0

  T. COST PER UNIT OF SERVICE (UNITS) (GROSS COSTS/LINE Q)                $0.00             $0.00           $0.00            $0.00            $0.00
  U. COST PER STAFF HOUR (GROSS COSTS/LINE S)                             $0.00             $0.00           $0.00            $0.00            $0.00




1cc03e4c-8dcc-46e3-8c15-e207a401cbfd.xls - 7895ODFG-P                                                                                             3 of 7
                                                    DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS
                                                           DRUG MEDI-CAL FISCAL DETAIL
                                                      REPORT OF EXPENDITURES AND REVENUES
                                                                    FY 2008-09


  COUNTY                                                            0
  CONTRACTOR                                                        0                   MEDI-CAL PROV. NO.                           0
  CONTRACT PERIOD                                                   0                   CADDS PROVIDER NO.                           0

     TYPE OF PROGRAM - ODF Group - Perinatal

                                                                         TOTAL             PRIVATE                      NNA/PUBLIC       TOTAL MC/
                     CATEGORIES                                         PROGRAM             PAY          MEDI-CAL        FUNDED          NNA/PUBLIC
  PERSONNEL SERVICES
   Salaries & Wages                                                              0.00                0              0                0            0.00
   Employee Benefits                                                             0.00                0              0                0            0.00
   TOTAL PERSONNEL SERVICES                                                  0.00                 0.00         0.00            0.00              0.00
  DIRECT SERVICES
   Clothing & Personal Supplies                                                  0.00                0              0                0            0.00
   Food                                                                          0.00                0                               0            0.00
   Laundry Services & Supplies                                                   0.00                0              0                0            0.00
   Pharmaceutical                                                                0.00                0              0                0            0.00
   Other (Specify)                                                               0.00                0              0                0            0.00
   SUBTOTAL DIRECT SERVICES                                                  0.00                 0.00         0.00            0.00              0.00
  EQUIPMENT, MATERIALS & SUPPLIES
   Depreciation-Equipment                                                        0.00                0              0                0            0.00
   Maintenance-Equipment                                                         0.00                0              0                0            0.00
   Medical, Dental, and Labratory Supplies                                       0.00                0              0                0            0.00
   Membership Dues                                                               0.00                0              0                0            0.00
   Rents & Leases Equipment                                                      0.00                0              0                0            0.00
   Small Tools & Instruments                                                     0.00                0              0                0            0.00
   Training                                                                      0.00                0              0                0            0.00
   Other (Specify)                                                               0.00                0              0                0            0.00
   SUBTOTAL EQUIPMENT, MATERIALS & SUPPLIES                                  0.00                 0.00         0.00            0.00              0.00
  OTHER OPERATING EXPENSES
   Communications                                                                0.00                0              0                0            0.00
   Depreciation-Structures & Improvements                                        0.00                0              0                0            0.00
   Household Expenses                                                            0.00                0              0                0            0.00
   Insurance                                                                     0.00                0              0                0            0.00
   Interest Expense                                                              0.00                0              0                0            0.00
   Leased Property Maintenance, Structures Improvements & Grounds                0.00                0              0                0            0.00
   Maintenance-Structures, Improvements & Grounds                                0.00                0              0                0            0.00
   Miscellaneous Expense                                                         0.00                0              0                0            0.00
   Office Expense                                                                0.00                0              0                0            0.00
   Publications and Legal Notices                                                0.00                0              0                0            0.00
   Rents & Leases-Land, Structures & Improvements                                0.00                0              0                0            0.00
   Taxes & Licenses                                                              0.00                0              0                0            0.00
   Drug Screenings & Other Testing                                               0.00                0              0                0            0.00
   Utilities                                                                     0.00                0              0                0            0.00
   Other (Specify)                                                               0.00                0              0                0            0.00
   SUBTOTAL OTHER OPERATING EXPENSES                                         0.00                 0.00         0.00            0.00              0.00
  PROFESSIONAL & SPECIAL SERVICES                                            0.00                    0              0                0           0.00
  TRANSPORTATION
   Transportation                                                                0.00                0              0                0            0.00
   Travel                                                                        0.00                0              0                0            0.00
   Gas, Oil, & Maintenance - Vehicles                                            0.00                0              0                0            0.00
   Rents & Leases-Vehicles                                                       0.00                0              0                0            0.00
   Depreciation-Vehicles                                                         0.00                0              0                0            0.00
   SUBTOTAL TRANSPORTATION                                                   0.00                 0.00         0.00            0.00             0.00
   TOTAL NONPERSONNEL                                                        0.00                 0.00         0.00            0.00             0.00
   Indirect Costs                                                            0.00                    0              0                0          0.00
  PROVIDER TOTAL                                                            $0.00              $0.00          $0.00           $0.00            $0.00
  DMC COUNTY ADMINISTRATION TOTAL                                           $0.00                                   0                          $0.00
  OVERALL TOTAL                                                             $0.00              $0.00          $0.00           $0.00            $0.00

  DIRECT COSTS (Only if both NNA and D/MC funding is identified)                                                    0                0




1cc03e4c-8dcc-46e3-8c15-e207a401cbfd.xls - 7895ODFG-P                                                                                                 4 of 7
                                                                         DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS
                                                                                 DRUG MEDI-CAL FISCAL DETAIL
                                                                            DRUG MEDI-CAL PROGRAM COST SUMMARY
                                                                                          FY 2008-09

                                                                                          ODF Group - Perinatal

COUNTY                                                            0                                 MEDI-CAL PROV. NUMBER                              0
PROVIDER                                                          0                                 CADDS PROVIDER NUMBER                              0


                                                                                    ADJUSTMENT OF TOTAL COST
                                                                                                           1                2                 3                 4                 5
                                                                                                        TOTAL          LESS DIRECT       LESS DIRECT
                                                                                                      NNA & DMC           NNA               DMC              ADJUSTED
                                  CATEGORY                                                          PROVIDER COSTS       COSTS             COSTS           PROGRAM COST
            A. PERSONNEL SERVICES                                                                                  0
            B. DIRECT SERVICES                                                                                     0
            C. EQUIPMENT, MATERIAL, & SUPPLIES                                                                     0
            D. OTHER OPERATION EXPENSES                                                                            0
            E. PROFESSIONAL & SPECIAL SERVICES                                                                     0
            F. TRANSPORTATION                                                                                      0                                                            DMC
            G. INDIRECT COSTS                                                                                      0                                                           COUNTY
            G1. DMC COUNTY ADMINISTRATION                                                                          0                                                            ADMIN
            H. TOTAL COSTS                                                                                         0                 0                 0                0                 0

                                                                        MEDI-CAL PROVIDER COST CALCULATION


                                                                                                                                           TOTAL
    01      TOTAL SERVICE COSTS                                                                                                                    0                                               01
    02      TOTAL SERVICE UNITS                                                                                                                    0                                               02
    03      COST PER UNIT OF SERVICE                                                                                                             0.00                                              03
    04      STATEWIDE MAXIMUM ALLOWABLE RATE OR PRORATED RATE                                                                                   63.62                                              04


                                                                                                                                         ADJUSTED/            TOTAL
                                                                                                     TOTAL UNITS         DENIED          ERRONEOUS           ADJUSTED
DRUG MEDI-CAL (DMC) RECONCILIATION OF CLAIMS (UNITS)                                                  SUBMITTED           UNITS            UNITS            DMC UNITS

    04a     1st Reporting Period - July thru September                                                             0                 0                 0                0                          04a
    04b     2nd Reporting Period - October thru June                                                               0                 0                 0                0                          04b
    04c     3nd Reporting Period - April thru June                                                                 0                 0                 0                0                          04c
   04c1     Minor Consent - July thru September - 7N AID Code Clients                                              0                 0                 0                0                          04c1
   04c2     Minor Consent - October thru June - 7N AID Code Clients                                                0                 0                 0                0                          04c2
   04c3     Minor Consent - April thru June - 7N AID Code Clients                                                  0                 0                 0                0                          04c3
   04c4     Minor Consent - July thru June - Non 7N AID Code Clients                                               0                 0                 0                0                          04c4
   04c5     Non-Minor Consent - 100% SGF                                                                           0                 0                 0                0                          04c5
                                                                                  TOTAL                            0                 0                 0                0

                                                                                                      BEGINNING           DMC               FINAL             FINAL           TOTAL NNA
                                                                                                         NNA           UNALLOWABLE          NNA                DMC             AND DMC
NEGOTIATED NET AMOUNT (NNA) UNITS OF SERVICE                                                            UNITS             UNITS            UNITS              UNITS             UNITS

    05      NNA and DMC Adjusted Units of Service                                                                  0                 0                 0                0                 0        05
                                                                                                                                                                                      OKAY
COST OF DRUG MEDI-CAL UNITS OF SERVICE
    09      COST - (Line 3 X Total Adjusted Units Line)                                                                                              0                                             09
    10a     COUNTY MEDI-CAL ADMINISTRATION                                                                                                           0                                             10a
    10b     DIRECT DMC COSTS                                                                                                                         0                                             10b
    11      TOTAL MEDI-CAL COSTS (Add Lines 9 + 10a + 10b)                                                                                           0                                             11
    12      TOTAL MEDI-CAL COST PER UNIT (line 11/ Total Adjusted Units Line)                                                                      0.00                                            12
    13      MAXIMUM DMC ALLOWABLE (Line 4 × Total Adjusted Units Line)                                                                               0 Federal Share         State Share           13
    14      DRUG MEDI-CAL ALLOWED (Lesser of Lines 11 or 13)                                                                                         0    50.00%              50.00%               14
   14a(1)      Allowed for July - Sep (04a × the lesser line 12 or 4)                                                                             0.00          0.00               0.00        14a(1)
   14a(2)      Allowed for July - Sept (04c1 × the lesser line 12 or 4) - Minor Consent Perinatal                                                 0.00          0.00               0.00        14a(2)
                                                                                                                                                          50.00%              50.00%
   14b(1)      Allowed for Oct - June (04b × the lesser line 12 or 4)                                                                             0.00          0.00               0.00        14b(1)
   14b(2)      Allowed for Oct - June (04c2 × the lesser line 12 or 4) - Minor Consent Perinatal                                                  0.00          0.00               0.00        14b(2)
                                                                                                                                                          54.35%              45.65%
   14c(1)      Allowed for Apr - June (04c X the lesser line 12 or 4)                                                                             0.00          0.00               0.00        14c(1)
   14c(2)      Allowed for Apr - June (04c3 X the lesser line 12 or 4) - Minor Consent                                                            0.00          0.00               0.00        14c(2)
                                                                                                                                                                               100%
    14d        Allowed for Minor Consent (Non-Perinatal) - Non 7N (100% SGF)                                                                           0                           0.00            14d
    14e        Allowed for Non-Minor Consent - 100% SGF                                                                                                0                           0.00            14e
    14f        Total of 14a(1), 14a(2), 14b(1), 14b(2), 14d, and 14e                                                                                   0              0.00         0.00            14f


REVENUE FROM DRUG MEDI-CAL UNITS OF SERVICE                                                                                                                   50%               50%
    15      REVENUE/FEES (Share of Costs)                                                                                                              0              0.00            0.00         15


NET DRUG MEDI-CAL COSTS
    16      NET COST (Line 14f minus Line 15)                                                                                                          0                0                 0        16
    17      LESS: AMOUNT RECEIVED                                                                                                                                                                  17
    18      BALANCE DUE (COUNTY) PROVIDER                                                                                                                                                          18



     1cc03e4c-8dcc-46e3-8c15-e207a401cbfd.xls - 7990ODFG-P                                                                                                                                5 of 7
            COST REPORT APPLICATION FUNDING WORKSHEET                                                    FY 2008-09

County:                                           0
Provider:                                         0                                                                                                                             DMC #                                0       CADDS #                    0
Modality:                      ODF Group - Perinatal
                                                                                                                                                                                                       NNA Hours:                    0    Staff Hours
                                                                                                                                                                                                        DMC Units:                   0    Individuals
                                                                                                                                                                                                       NNA Units:                    0    Individuals
                                                                                                                                                                                             DMC Cost Per Unit:                    0.00
                                                                                                                                                                                             NNA Cost Per Unit:                    0.00

                                                                                                                                                                                             Total Costs                             0

                                                   NNA                          DMC
                                                     0                            0     Total Cost
                                                     0                            0     Less: Direct Cost                                                                                                                  EDITS
                                                    NA                            0     Less: DMC Admin.
                                                     0                            0     Subtotal                                                                                        1.   NNA Staff Hours               OKAY
                                                     0                            0     Units                                                                                           2.   Total Units                   OKAY
                                                    NA                           NA     Cost per unit                                                                                   3.   Denied/Adjusted Total         OKAY
                                                                                                                                                                                        4.   Denied vs. Submitted          OKAY
                                                                                                                                                                                        5.   SMA/Prorated Rate             OKAY
                                                                                                                                                                                        6.   DMC County Admin              OKAY
                                                                                                                                                                                        7.   Cost Shifting                 OKAY

Note: This OK Worksheet will automatically calculate the DMC FFP ( FL40 and                                                                                                                                              Notes
      FL40a) and SGF (FL40b and FL70). The Fee/DMC Share of Costs will be                                                                                                               1.   No correction needed
      carried over from the Data Entry Sheet. All other funding lines will be                                                                                                           2.   No correction needed
      automatically calculated and combined in the line titled "Various". You are no longer                                                                                             3.   No correction needed
      be required to manually enter all the funding lines on this worksheet to match the Paradox                                                                                        4.   No correction needed
      Fiscal Detail as required in past years. The funding line detail on the Paradox Fiscal                                                                                            5.   No correction needed
      Detail will be used to support the total NNA and DMC cost on this worksheet.                                                                                                      6.   No correction needed
                                                                                                                                                                                        7.   No correction needed


                                                                                             NNA              DMC                     Drug Medi-Cal Breakout
Line #       Funding Sources                                                                Amount           Amount       Title XIX        Non-7N Minor    Other 100% SGF   Total
    40      Drug Medi-Cal (Fed Share Only) Fed Cat #93.778                                                                                                                          0
   40a      Perinatal Medi-Cal (Fed Share Only) Fed Cat #93.778                                                       0               0                                             0
   40b      Perinatal (PTEP) Match to Medi-Cal                                                                        0               0               0                0            0
    84      Fees / D/MC Share of Costs                                                                                0               0               0                0            0
    70      State General Fund - Match to Medi-Cal                                                                                                                                  0
 various    Various (Actual funding lines are displayed on the Fiscal Detail)                        0                0               0               0                0            0

                                                                  Total:                             0                0               0               0                0            0
                  EDITS                                      FUNDING NEEDED                          0                0                                                             0
                                                                                             OKAY             OKAY                                                          OKAY

                                                                 DIFFERENCE                          0                0                                                             0

       Direct DMC Costs:                                                            0
       Direct NNA Costs:                                                            0
DMC County Administration                                                           0
Group Sessions:                                                                     0
   Combined Cost Per Unit:                                                         NA
 DMC Maximum Rate                                                               63.62
 DMC Costs                                                                          0
 DMC Maximum Allowable                                                              0
 DMC Excess Costs                                                                   0
 NNA Costs                                                                          0

                                    REMINDER:             FUNDING AND UNIT INFORMATION SHOWN ON THIS WORKSHEET SHOULD
                                                          BE THE SAME AS THE FUNDING AND UNIT INFORMATION REPORTED ON THE
                                                          PARADOX COST REPORT.




             1cc03e4c-8dcc-46e3-8c15-e207a401cbfd.xls - ODFGFUND-P                                                                                                                                                                        6 of 7
                                          FY 2008-09 Cost Report
                                                  Comparison Sheet

                                                ODF Group - Perinatal

                                   County: 0
                                  Provider: 0
                          DMC Number: 0
                       CADDS Number: 0



                                         NNA Funding Information
         NNA Program Codes

            Type of Information                 Form 7895            Form 7990          OK Worksheet      Paradox Fiscal Detail


NNA Staff Hours                                     0                   NA                    0

NNA Total Costs                                     0                   NA                    0

NNA # of Individuals                                0                    0                    0



NNA Direct Costs                                    0                    0                    0




                                        DMC Funding Information
         DMC Program Codes

            Type of Information                 Form 7895            Form 7990          OK Worksheet      Paradox Fiscal Detail


DMC Total Costs                                     0                    0                    0

DMC Per Person (Individuals)                        0                    0                    0



DMC Direct Costs                                    0                    0                    0

DMC County Administration (REQUIRED)                0                    0                    0




IMPORTANT NOTE: The information in the OK Worksheet column should match the Cost Report Fiscal Detail Pages in Paradox




1cc03e4c-8dcc-46e3-8c15-e207a401cbfd.xls - Comparison                                                                       7 of 7

								
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