Illinois Administrative Code
Title 89 - SOCIAL SERVICES
Part 148 - HOSPITAL SERVICES
Subpart F - EMERGENCY PSYCHIATRIC DEMONSTRATION PROGRAM
Table A - Renal Participation Fee Worksheet
Universal Citation: 89 IL Admin Code ยง A
Current through Register Vol. 48, No. 12, March 22, 2024
Date ___________________
Initialed _________________
Patient Identification Number __________________
PATIENT'S NAME ________________________________________________________
LastFirstMiddle Initial
In questions 1 through 4 below, please circle one number or group of numbers:
1. |
NUMBER OF PERSONS IN FAMILY |
1 |
2 |
3 |
4 |
5 |
6 or more |
2. |
NUMBER OF CHILDREN |
1 |
2 |
3 |
4 |
5 or more |
|
3. |
AGE OF OLDEST CHILD IN YEARS |
0-5 |
6-15 |
16-17 |
18 and over |
||
4. |
AGE OF HEAD OF HOUSEHOLD |
Under 35 |
35-54 |
55-64 |
65 and over |
||
BUREAU OF LABOR STATISTICS (BLS) EQUIVALENCE FACTOR= |
__________ (see Table B) |
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