Pa. Code tit. 55, pt. VI, subpt. C, ch. 4310, BILLING AND COLLECTION, app A
| Annual Discretionary Income | Monthly Liability for Institutional Care | Annual Discretionary Income | Monthly Liability for Institutional Care |
| 0-249 | -3- | 9000-9499 | 329. |
| 250-499 | 11. | 9500-9999 | 356. |
| 500-999 | 22. | 10,000-10,499 | 384. |
| 1000-1499 | 36. | 10,500-10,999 | 413. |
| 1500-1999 | 50. | 11,000-11,499 | 443. |
| 2000-2499 | 65. | 11,500-11,999 | 474. |
| 2500-2999 | 79. | 12,000-12,499 | 506. |
| 3000-3499 | 94. | 12,500-12,999 | 540. |
| 3500-3999 | 108. | 13,000-13,499 | 574. |
| 4000-4499 | 122. | 13,500-13,999 | 610. |
| 4500-4999 | 137. | 14,000-14,499 | 646. |
| 5000-5499 | 151. | 14,500-14,999 | 684. |
| 5500-5999 | 170. | 15,000-15,499 | 723. |
| 6000-6499 | 189. | 15,500-15,599 | 763. |
| 6500-6999 | 210. | 16,000-16,499 | 804. |
| 7000-7499 | 231. | 16,500-16,999 | 846. |
| 7500-7999 | 254. | 17,000 and over | 1/20 of |
| 8000-8499 | 278. | discretionary | |
| 8500-8999 | 303. | income +$23.00 |
Dear
Under Sections 501, 502 and 503 of the Mental Health and Intellectual Disability Act of 1966, you are liable for services provided the client mentioned above. According to the Department of Human Service's Regulations promulgated as Chapter 4310 your monthly liability has been assessed in the maximum amount specified above. You will be billed monthly for services provided in accordance with charges established by the Department of Human Services or the amount of your liability, whichever is the lesser amount. It is your responsibility to report significant changes in income which may effect the amount of your liability.
If payment of the liability will cause a hardship for you, you may request an abatement or modification of liability by completing the form on the reverse side of this notice with a full explanation of the hardship created. Forward the PW-83 and a copy of the Determination of Liability - PW-833 to the Secretary of Public Welfare, Box 2675, Harrisburg, Pennsylvania 17105. If you need assistance, the facility providing the service will assist you in completing this request.
The basis for granting an abatement or modification of liability are detailed in the Notice of Rights - S1-83 provided with the Notice of Assessment - PW-83.
Debts that cannot be considered in granting abatement or modification of liability include:
(a) mortgage or rent on principal residence;
(b) utility payments;
(c) payments on first automobile;
(d) medical expenses already considered;
(e) debts incurred after treatment has begun;
(f) any other debt or payment for which the client has not incurred a legal obligation to pay;
(g) retail charge purchases for personal use items, food and/or commodities.
Any request for review must be made within 30 days from receipt of this notice. The time limit will not apply where hardship has been caused by unforeseen circumstances over which you have no control.
____________________________________ | ____________________________________ |
INSTITUTIONAL COLLECTIONS OFFICER | DATE |
To appeal a decision regarding the assessment of liability, a written request for a fair hearing must be submitted to the Office of Hearings and Appeals, Department of Public Welfare, P. O. Box 2675, Harrisburg, Pa. 17120, within 30 days of the date from which this decision was mailed.
In your request for a fair hearing you must state the reason(s) why you are appealing the Department's decision. It is also necessary that you list your name, address and telephone number, with area code, and whether or not you will be represented by counsel. If you are represented by counsel, list counsel's name, address, and telephone number, with area code, as the Office of Hearings and Appeals may elect to hold the hearing by telephone.
At the hearing, the appellant may represent himself or be represented by counsel, and has the following rights:
1. To present evidence on his own behalf, to bring witnesses, and to confront and cross-examine witnesses the Department will produce to support its decision or action.
2. To examine prior to the hearing, as well as during the hearing, that material from the patient's records that the Department will introduce as evidence in the hearing to support its decision or action.
3. To be provided with the names, addresses and telephone numbers of the Department's staff members and witnesses who will be present at the hearing.
Pa. Code tit. 55, pt. VI, subpt. C, ch. 4310, BILLING AND COLLECTION, app A
The provisions of this Appendix A amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. §§ 4201(2) and (8) and 4202).