Form CP-7 "Nursing Facility Transition to the Community (Non-mfp)" - New Jersey

What Is Form CP-7?

This is a legal form that was released by the New Jersey Department of Human Services - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2014;
  • The latest edition provided by the New Jersey Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CP-7 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Human Services.

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Download Form CP-7 "Nursing Facility Transition to the Community (Non-mfp)" - New Jersey

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New Jersey Department of Human Services
NURSING FACILITY TRANSITION TO THE COMMUNITY (NON-MFP)
Date Faxed
Name of Person/ Title Completing Form
To: Alisa Mead
Assistant MFP Director
(609) 588-7267 (Phone)
Phone Number
(609) 588-3330 (FAX)
Participant Name
Social Security Number
Date of Birth
Age
SSI Recipient
Yes
No
Medicaid Number
Effective Date
Medicare Number
Met MLTSS eligibility and did not transition due to meeting the
Cost Effectiveness Threshold.
Discharge Services:
Cost Effective IDT requested
State Plan Services
Private Pay
Date: ____/____/_________
MLTSS
Medicare Services
Discharge Facility Name
Facility Type
Case Conference Initiated
_________________________
NF:
Discharge Facility Address
SCNF:
_________________________
Type:
Date of Admission to NF/SCNF
IDT Done
Date
Yes
No
Date of Discharge from NF/SCNF
Discharge To
Private Home/Apartment
ALR/CPCH
AFC
RHCF
Phone
Address
Name of Care Manager
Phone
Email of Care Manager
What constitutes a transition?
To be considered a discharge or transition from a NF to the community and reported to OCCO,
contact must be made at the facility through a NJ Choice Assessment, follow-up, Options
Counseling, and/or a Section Q referral. Options Counseling and any assistance given to the
client needs to be documented in the IPOC section of the NJ Choice Assessment and your
monitoring notes. NOTE: IF TRANSITION IS A MFP, USE MFP 75
CP-7
MAY 14
New Jersey Department of Human Services
NURSING FACILITY TRANSITION TO THE COMMUNITY (NON-MFP)
Date Faxed
Name of Person/ Title Completing Form
To: Alisa Mead
Assistant MFP Director
(609) 588-7267 (Phone)
Phone Number
(609) 588-3330 (FAX)
Participant Name
Social Security Number
Date of Birth
Age
SSI Recipient
Yes
No
Medicaid Number
Effective Date
Medicare Number
Met MLTSS eligibility and did not transition due to meeting the
Cost Effectiveness Threshold.
Discharge Services:
Cost Effective IDT requested
State Plan Services
Private Pay
Date: ____/____/_________
MLTSS
Medicare Services
Discharge Facility Name
Facility Type
Case Conference Initiated
_________________________
NF:
Discharge Facility Address
SCNF:
_________________________
Type:
Date of Admission to NF/SCNF
IDT Done
Date
Yes
No
Date of Discharge from NF/SCNF
Discharge To
Private Home/Apartment
ALR/CPCH
AFC
RHCF
Phone
Address
Name of Care Manager
Phone
Email of Care Manager
What constitutes a transition?
To be considered a discharge or transition from a NF to the community and reported to OCCO,
contact must be made at the facility through a NJ Choice Assessment, follow-up, Options
Counseling, and/or a Section Q referral. Options Counseling and any assistance given to the
client needs to be documented in the IPOC section of the NJ Choice Assessment and your
monitoring notes. NOTE: IF TRANSITION IS A MFP, USE MFP 75
CP-7
MAY 14