§ 6200.35. Standard room and board contract.
The following standard room and board contract shall be used for clients funded through the county mental retardation program:
STANDARD ROOM AND BOARD CONTRACT
THIS AGREEMENT, made on
between
, hereinafter referred to as client, (name of client)
and,
at
(provider agency administering program) (address of administering provider agency) hereafter referred to as provider agency.
WITNESSETH:
Whereas, the client is participating in a program furnished by the provider agency; and
Whereas, room and board is furnished by the provider agency at
(address of residence)
(1) Client agrees to pay provider agency $
(if client is funded through the County Mental Retardation Program exclusively, the client’s monthly share of room amd board is 72% of the SSI maximum rate, or the actual cost of room and board if the actual cost is less than 72% of the SSI maximum rate; this is the total amount that client shall pay for room and board).
(2) Client agrees to pay provider agency $
(if client resides in a jointly certified domiciliary care and licensed community residental mental retardation facility, the client’s share is 72% of the SSI maximum rate which includes the domiciliary care supplement for room and board).
(3) Client agrees to pay provider agency $
(if client pays their own rent directly to a landlord, but food is supplied through a provider agency) for food. The client shall only pay 32% of the SSI maximum rate for board.
(4) Client agrees to pay provider agency $
(if client pays rent to provider agency, but client purchases their own food) for board. The client shall only pay 40% of the SSI maximum rate for room.
(5) Payment shall be made on a monthly basis and shall be due and payable the first day of each month. Payments for periods of less than a month shall be pro-rated and shall be due and payable prior to leaving the facility.
(6) Monies for room and board shall be paid to the person designated by the provider agency. Such person shall issue a reciept showing amount of payment and period covered.
(7) If at any time the client’s total available income is less than the SSI maximum rate, 72% of the available income shall be charged to fulfill the client’s monthly obligation in Paragraph 1 of this Agreement. The client shall always be guaranteed at least $30 per month for spending money.
SIGNED:
County or Provider Agency Date
Witness Date
Client or Person Signing on Date
Client’s Behalf
If another person signs on behalf of the client indicate his/her relationship to the client
The provisions of this § 6200.35 adopted March 23, 1990, effective July 1, 1990, 20 Pa.B. 1706; amended September 21, 1990, effective September 22, 1990, 20 Pa.B. 4864. Immediately preceding text appears at serial pages (146943) to (146945).
This section cited in 55 Pa. Code § 6200.17 (relating to room and board charges from other sources of income); 55 Pa. Code § 6200.19 (relating to actual room and board costs); 55 Pa. Code § 6200.20 (relating to delay in client’s income); and 55 Pa. Code § 6200.31 (relating to room and board contract).
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