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._______ ._________.I .____I _ ___. .____ __ ___. MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD NEVADA STATE DIVISION OF SOCIAL SERVICES PATIENT LIABILITY (P/L) BUDGET ─ NON-SPOUSAL IMPOVERISHMENT Case Name Case Number Date Worker MAINTENANCE ALLOWANCE REMARKS/DOCUMENTATION EARNED INCOME SPOUSE/DEPENDENT’S GROSS EARNINGS.........................................__________ LESS: 1. Tax and Social Security ......................____________ 2. Other .................................................____________ 3. Other .................................................____________ TOTAL EXPENSES ..............................................................................__________ NET EARNINGS...................................................................................__________ UNEARNED INCOME RSDI ...................................................................................................__________ SSI......................................................................................................__________ UIB.....................................................................................................__________ Pensions ............................................................................................__________ Other .................................................................................................__________ TOTAL UNEARNED INCOME...............................................................__________ ALLOWANCE SPOUSE/DEPENDENTS’ TOTAL NEEDS ...............................................__________ TOTAL NET INCOME (Earned and Unearned) ....................................__________ MAINTENANCE ALLOWANCE.............................................................__________ PATIENT LIABILITY INCOME MONTH:______________ FOR: _______________ (MONTH) TOTAL GROSS MONTHLY INCOME.............................................. $ __________ Less Involuntary Mandatory Deductions .................................... $−__________ Less Income Excluded from P/L .................................................. $−__________ TOTAL PATIENT LIABILITY INCOME............................................. $ __________ LESS: 1. Personal Needs Allowance................................__________ 2. Home Based Maintenance................................__________ 3. Spouse/Dependents’ Maintenance ..................__________ 4. Payments for Health Insurance.........................__________ 5. Incurred Medical Expenses ...............................__________ TOTAL DEDUCTIONS ................................................................... $ __________ PATIENT LIABILITY (Full Month) ................................................. $ __________ PARTIAL MONTH PRORATION Full Month Patient Liability......................................................... $ __________ Number of Days in the Month .................................................... ÷ __________ Daily Rate .......... = __________ Number of Days Institutionalized .............................................. x __________ Patient Liability for __________________ = $ __________ (MONTH) APPENDIX F MAABD BUDGETS PATIENT LIABILITY (P/L) BUDGET ─ NON- Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25 SPOUSAL IMPOVERISHMENT