Thursday, December 15, 2011

Registration With D.C. Dept. Mental Health -- June 12 1996

GOVERNMENT OF THE DISTRICT OF COLUMBIA
DEPARTMENT OF HUMAN SERVICES
COMMISSION ON MENTAL HEALTH SERVICES
WASHINGTON, D.C.  20032

Gary Freedman
3801 Connecticut Ave., NW #136
Washington, D  20008

Date: 07-24-96
Re: Freedman, Gary
CMHS # 230923

Our records show that you was/were admitted to the Commission on Mental Health Service on 06-12-96.  Based on our previous correspondence with you, we have determined that:

(x) Insurance will be billed.  Medicare A & B

( ) There is no record of insurance

The remaining balance will be your responsibility up to the maximum as stated below:

You will be billed:

( ) At the daily inpatient rate of $_______ per day until you have been billed $______ and $______ per month for each additional month of inpatient care.

(x) At the daily outpatient rate of $5.00 per visit not to exceed $17.00 per month for outpatient care.

( ) $______ per month for inpatient care.

Charges which exceed the amount of the liability stated above will be paid for by the D.C. Medical Assistance Program, by the D.C. Government, for by the Federal Government.

( ) You will not be billed for services.  Cost of care will be paid by the Federal Government, the District Government or Medical Assistance.

If any change in financial status occurs, please notify this office so that the ability to pay may be reviewed.  This notice will be void if material information provided by you is misrepresented or information is willfully withheld.  Such action will subject the responsible payor to the full cost of care and treatment.  The Commission on Mental Health Services reserves the right to review periodically the stated ability to pay.

This notice is for your information only.  It is not a bill.  If clarification is needed regarding this matter, please call 673-2061.

Sincerely yours,

Stephanie Sterrett (Stevie)
*Patient Services Coordinator
Patient Services Department

CMHS - 191 *SEH Contracted
(Rev. 10/89)

Commission on Mental Health
1536 U Street, N.W.
1st Floor
Washington, DC  20009

1 comment:

Gary Freedman said...

From September 1992 to June 1996 I was in out-patient treatment at the George Washington University Medical Center. No state or federal insurance was paid.