65-6.015. Financial Information and Verification

(1) The client or responsible party will complete and return to the department the Financial Information form (CF Form 280, effective September 2018), which is incorporated by reference and available at http://www.flrules.org/Gateway/reference.asp?No=Ref-10017, will be completed by the direct service worker for parents of children placed in the custody of the department under chapter 39, F.S. The form will be provided by the direct service worker, or may be obtained from the fee collection unit. This form will specify all gross income, benefit payments, third party benefits available to the client and responsible party, the number of persons dependent on that income, and other related information required to determine and verify the ability to pay for the cost of services provided. In addition, the client or responsible party must identify the assets that may be available to assure payment of the fees. The form, and instructions for its completion, will be provided at the time a person applies for services, becomes a client or is admitted to a residential facility.

(2) The direct service worker, or a person designated by the Regional Managing Director or Facility Administrator, shall assist the client or responsible party in completing the form.

(3) The client or responsible party must complete, sign and return the form to the department within 30 days of its receipt. If the responsible party is not present at the time the client is admitted for services or the client is unable to complete the form, a blank form will be delivered or mailed to the client or responsible party within 10 days of the client’s admission for services. A completed and signed form must be returned to the department within 30 days of receipt of the form.

(4) The Financial Information form must include a signed statement specifying that:

(a) The information is true and correct;

(b) Changes in gross income or expenses in excess of $50 a month, in the number of individuals dependent on that income, or in the availability of third party benefits or benefit payments shall be reported to the department within 15 days of the change;

(c) The client or responsible party may, at his option, assign third party or benefit payments to the department.

(5) Except as provided in subsection (8) of this rule, the client or responsible party is required to submit a new Financial Information form annually, unless notification pursuant to paragraph (4)(b) of this rule was provided during the year. It must be submitted within 15 days after the proper blank form is provided by the department. If the form is not returned within that time frame, the department will effect delivery of another blank form by hand or certified mail and request a return within 15 days.

(6) If the client or responsible party fails to complete or sign the initial form within the required time frame, the department shall:

(a) Bill the client or responsible party for the cost of services less reimbursements from third party payors; and,

(b) Enter suit to enforce the financial information requirement, if the bill is not paid and the department determines that suit is likely to identify revenue sources.

(7) The department shall verify any of the information reported on the financial information form in accordance with the most economical uniform procedures.

(8) In the case of an adult unmarried client or a client in foster care, if there is knowledge that the client’s financial condition has not changed, the fee collection unit will continue collection of the client’s or responsible party’s current fee. The direct service worker may sign a Financial Information – Short Form (CF Form 280A, effective September 2018) which is incorporated by reference and available at available at http://www.flrules.org/Gateway/reference.asp?No=Ref-10016, certifying that the information on file has not changed except as noted on the form.

Rulemaking Authority 402.33(6)(b) FS. Law Implemented 402.33 FS. History–New 1-23-85, Formerly 10-6.15, Amended 1-27-86, 3-29-89, 4-27-93, Formerly 10-6.015, Amended 11-26-18.