Code of Massachusetts Regulations
105 CMR - DEPARTMENT OF PUBLIC HEALTH
Title 105 CMR 920.000 - Establishing A Uniform Schedule Of Assessments For Direct Pay Patients At The Department Of Public Health Hospitals
Section 920.010 - Financial Information Form

Universal Citation: 105 MA Code of Regs 105.920

Current through Register 1531, September 27, 2024

EXHIBIT A

Adj. Annual Income	In Family	0	1	2	3	4	5	6	7 +
Under 2000	30	30	30	30	30	30	30	30
2000 To 2999	30	30	30	30	30	30	30	30
3000 To 3999	83	30	30	30	30	30	30	30
4000 To 4999	166	30	30	30	30	30	30	30
5000 To 5999	249	30	30	30	30	30	30	30
6000 To 6999	333	82	30	30	30	30	30	30
7000 To 7999	416	165	50	30	30	30	30	30
8000 To 8999	449	248	133	30	30	30	30	30
9000 To 9999	583	332	217	30	30	30	30	30
10000 To 10999	666	415	300	70	30	30	30	30
110000 To 11999	749	498	383	38	30	30	30	30
12000 To 12999	833	582	467	237	122	30	30	30
13000 To 13999	916	665	550	320	205	90	30	30
14000 To 14999	999	748	633	403	288	173	30	30
15000 To 15999	1083	832	717	487	372	257	30	30
16000 To 16099	1166	832	800	570	455	340	110	30
17000 To 17999	1249	998	883	653	338	423	193	78
18000 To 18999	1333	1082	967	737	622	507	277	162
19999 To 19999	1416	1165	1050	820	705	590	360	245
20000 To 20999	1499	1248	1133	903	788	673	443	328
21999 To 22999	1583	1332	1217	987	872	757	527	412
23000 To 23999	1749	1498	1383	1153	1038	923	693	578
24000 To 24999	1833	1582	1467	1237	1122	1007	777	662
25000 To 25999	1916	1665	1550	1320	1205	1090	860	745
Add *83.00 for each additional $1,000	+83	+83	+83	+83	+83	+83	+83	+83

EXHIBIT B

HUMAN SERVICES FINANCIAL INFORMATION FORM

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Code of Massachusetts Regulations105 CMR - DEPARTMENT OF PUBLIC HEALTHTitle 105 CMR 920.000 - Establishing A Uniform Schedule Of Assessments For Direct Pay Patients At The Department Of Public Health HospitalsSection 920.010 - Financial Information Form

Code of Massachusetts Regulations
105 CMR - DEPARTMENT OF PUBLIC HEALTH
Title 105 CMR 920.000 - Establishing A Uniform Schedule Of Assessments For Direct Pay Patients At The Department Of Public Health Hospitals
Section 920.010 - Financial Information Form