ACP Financial Information and Agreements

Anazao Community Partners (ACP) works to fund our services by various means, including partnering with the Mental Health and Recovery Board (MHRB) of Wayne and Holmes Counties, and the Holmes and Wayne Counties Departments of Job and Family Services (HCDJFS/WCDJFS). We are contracted with many commercial insurance companies for some services. In addition, we partner with the United Way of Wayne and Holmes Counties and several area school districts for additional supportive funding.

The information requested below will allow ACP to determine eligibility options to cover costs for our services for you or your children. In partnering with these organizations, our goal is for you or your family to not incur any direct costs. This is not guaranteed, but providing information on this form allows us to determine eligibility for coverage. ACP staff may contact you for clarification or to obtain additional information.

Insurance Information

If your child has Aetna OhioRise, please add this information below then include your other MCO by clicking "Add new row".

Income Statement

This information is used to determine fee reductions or eligibility for other funding (including Temporary Assistance to Needy Families - TANF) for your services.

Household Members (please include the client, parent/guardian (if applicable), and other household members (ex: siblings, spouse, children, etc.):

Household Income

Please list each Employer or Income Source separately and click "Add new row" below to list additional Employers/Income sources for all members of the household.

Financial Agreements: By agreeing below, I authorize enrollment in the Mental Health and Recovery Board (MHRB) and PartnerSolutions Health Informatics Consortium (PSHIC). I request that ACP bill any eligible charges under that plan, and authorize payment of benefits to ACP for services provided. I understand that ACP uses a scale based on the size and income of my household to determine fees. I understand that I may be responsible for payment for services denied by my insurance or Medicaid/Managed Care Organization (MCO) plan. I understand that I must provide proof of income (current pay stub, recent tax form, statement from employer, etc.) to determine eligibility for some funding. I understand that if my family has no income, I must attest to this. I understand that I must provide ACP with proof of any change of income. I understand that not providing proof of income may result in my being charged the full hourly fee (up to $131 per hour) until this is provided. I understand that once my fee has been calculated, this will be provided to me. I understand that payment is due at the time of service.

By agreeing to this form I give permission to Anazao Community Partners to bill insurance on my behalf. I understand I need to provide updated insurance information throughout the year to ACP and to provide information requested by my insurance company to avoid delay of payment to our agency. I give ACP permission to contact my insurance company and/or my employer for other information regarding insurance.

I authorize payment of services provided by ACP to be paid directly to ACP. I authorize ACP to release any information regarding claims for services to my insurance carrier/managed care organization.