EXHIBIT A

Adj. Annual In Income 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

105 CNR: DEPARTMENT OF PUBLIC HEALTH

Adj. Annual In Income Family 0 1 2 3 4 5 6 7+

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 +83 +83 +83 +83 +83 +83 +83 +83 additional $1,000

EXHIBIT B

HUMAN SERVICES

FINANCIAL INFORMATION FORM

Name: SS No.

Birth date: Sex:

Former Patient: Marital Status:

Patient Address:

Name Financially Responsible Individual #1

(if different from above)

Address:

Relationship: SS No.

Name Financially Responsible Individual #2

Address:

Relationship: SS No.

If there are any additional number of Financially Responsible Individuals list names, addresses, relationships and social security numbers on an attached sheet.

THIRD PARTY INFORMATION Check types of coverage the patient is eligible for:

Blue Cross/Blue Shield Medicaid

Commercial Insurance Veteran's Carrier SSI

Medicare Other

Have these sources been billed to the full extent possible? YES NO If no, patient is not eligible for reduced rate.

PART A Gross Income (Enumerate in Part B) $ Total Exceptional Expenses (Enumerate in Part C) $ Change in Income (Describe circumstances and proof in Part D) $ Liquid Assets (Enumerate in Part E) $ TOTAL Adjusted Annual Income $ Number of Dependents Locate amount individual responsible for in a given calendar month on the "Financial Responsibility Table".

Individual responsible for a maximum of $ in a given month.

Using the "Annual Maximum Table" calculate the maximum amount the individual will be responsible for paying in any given twelve month period:

% X $ = $

PART B

WAGES

NAME OF ADDRESSES ANNUAL INCOME EMPLOYERS

PATIENT

FINANCIALLY RESPONSIBLE INDIVIDUAL #1

FINANCIALLY RESPONSIBLE INDIVIDUAL #2

UNEARNED INCOME

SOURCE AMOUNT

PATIENT

FINANCIALLY RESPONSIBLE INDIVIDUAL #1

FINANCIALLY RESPONSIBLE INDIVIDUAL #2

TOTAL INCOME

PART C - Exceptional Expenses. In the space below, enumerate exceptional expenses:

Expense Amount

TOTAL $

PART D ­ Change in income. Describe reason for change in income and proof of such change.

Include extraordinary sources of income.

PART E - LIQUID ASSETS

Cash $

Bank Deposits $

Securities $

TOTAL $

List names of banks funds held in:

Signature

I hereby attest, under penalties of perjury, that to the best of my knowledge the above information is correct.

Signature

I, , understand that I am responsible for contributing $ per month to my health care but no more than $ per year. If I do not fulfill this responsibility I understand that my bill will be sent to the Attorney General of the Commonwealth of Massachusetts for appropriate action. I further attest that I have been advised and understand the purposes and uses ofthis information(listed onattached sheet) and therefore consent to this information being held by the Department of Public Health.

Signature Patient or Financially Responsible Individual

Date

Signature Patient or Financially Responsible Individual

Treasurer's Initials

Signature of Interviewing Individual

PART F - Was the patient denied on assessment? If so, state reasons for denial.

PART G

Was review asked for? YES NO Was hearing requested? YES NO

What was the result:

REGULATORY AUTHORITY

105 CMR 920.000: M.G.L. c. 111, §§ 69I, 69E, 62I; c. 122, § 1.

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