Form LTC-2 "Notification From Long-Term Care Facility Admission or Termination of a Medicaid Beneficiary" - New Jersey

What Is Form LTC-2?

This is a legal form that was released by the New Jersey Department of Human Services - a government authority operating within New Jersey. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on July 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 LTC-2 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 LTC-2 "Notification From Long-Term Care Facility Admission or Termination of a Medicaid Beneficiary" - New Jersey

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Type:
New Jersey Department of Human Services
Request PAS
Division of Aging Services
Notice of Admission
NOTIFICATION FROM LONG-TERM CARE FACILITY
Notice of Termination
ADMISSION OR TERMINATION OF A MEDICAID BENEFICIARY
Notice of Transfer
I.
PATIENT INFORMATION
2. Social Security No.:
-
-
1. Name:
(Last)
(First)
3. Sex:
Female
Male
4. Date of Birth
/
/
5. HSP# (Medicaid) Case No. if applicable:
Confirmed By (CWA):
NJ Family Care
MLTSS
MCO:
II.
PROVIDER INFORMATION
1. Provider Number:
5. Provider Phone #:
6.
SCNF:
2. LTCF Name:
3. Address:
4. City, State, Zip:
III. PASRR STATUS (COMPLETE FOR ALL NEW ADMISSIONS)
1. Date of PASRR Level I
/
/
Screen:
2. Outcome of PASRR Level I Screen – For Positive Screens Check all that Apply
Negative
Positive:
MI
ID/DDD
MI and ID/DDD
30-Day Exempted Hospital Discharge
Categorical
/
/
3. If Positive, Date of PASRR Level II Evaluation:
Outcome of PASRR Level II Evaluation - Client Needs Specialized Services:
Yes
No
IV. REQUEST FOR PAS
Private to Medicaid
SCNF to NF
Transfer
PAS Exempt >20 Days
NF to SCNF
E-ARC PAS
Medicare to Medicaid
Out of State Approval Admission
Other:
V.
ADMISSION INFORMATION
1. Admission Date:
/
/
/
/
2. Date of PAS, if applicable:
3. Admitted from:
Community/Boarding Home
Psychiatric Hospital
/
/
Private to Medicaid - Anticipated Medicaid Effective Date:
Hospital
Other LTCF
Other
(specify):
/
/
4. Name of Hospital/LTCF:
Admission Date:
Address:
5. If admitted from Hospital/LTCF, give the name/address of previous residence (Hospital Name and Address or Home Address):
VI. TERMINATION INFORMATION
/
/
1. Discharge Date:
2. Discharged to:
Home-Community (including relative’s home)/ County of residence:
County of NF:
Facility Name:
County of Residence:
Other (specify):
Telephone Number of Discharge Site:
/
/
3. Death (Date):
In LTCF
In Hospital
VII. CERTIFICATION:
The facility certifies that the patient will reside only in those areas of the facility which are certified for
participation in the New Jersey Medicaid Program at the level of care authorized for this patient by the New Jersey Medicaid Program.
The facility also certifies that upon discharge to a hospital, the patient’s room/bed will be reserved for the full period of time covered
by the New Jersey Medicaid Bed Reserve Policy. If nursing facility bills Medicaid for long term care services, the person signing this form
certifies that the facility has a valid PAS on file. This form completed by:
Phone Number:
Name:
Date:
Title:
VIII. CWA USE ONLY
/
/
Medicaid Effective Date:
Medicaid ONLY (PR-1 Attached)
COUNTY WELFARE OFFICE
SSI Only (PR-1 Required, Contact DHS)
Street Address:
Not Eligible
/
/
Transcript Requested - Date:
City and Zip:
Remarks:
Name of Case Worker:
Date:
LTC-2
JUL 14
Original-CWA
Copy-OCCO RO
Copy-Provider
Type:
New Jersey Department of Human Services
Request PAS
Division of Aging Services
Notice of Admission
NOTIFICATION FROM LONG-TERM CARE FACILITY
Notice of Termination
ADMISSION OR TERMINATION OF A MEDICAID BENEFICIARY
Notice of Transfer
I.
PATIENT INFORMATION
2. Social Security No.:
-
-
1. Name:
(Last)
(First)
3. Sex:
Female
Male
4. Date of Birth
/
/
5. HSP# (Medicaid) Case No. if applicable:
Confirmed By (CWA):
NJ Family Care
MLTSS
MCO:
II.
PROVIDER INFORMATION
1. Provider Number:
5. Provider Phone #:
6.
SCNF:
2. LTCF Name:
3. Address:
4. City, State, Zip:
III. PASRR STATUS (COMPLETE FOR ALL NEW ADMISSIONS)
1. Date of PASRR Level I
/
/
Screen:
2. Outcome of PASRR Level I Screen – For Positive Screens Check all that Apply
Negative
Positive:
MI
ID/DDD
MI and ID/DDD
30-Day Exempted Hospital Discharge
Categorical
/
/
3. If Positive, Date of PASRR Level II Evaluation:
Outcome of PASRR Level II Evaluation - Client Needs Specialized Services:
Yes
No
IV. REQUEST FOR PAS
Private to Medicaid
SCNF to NF
Transfer
PAS Exempt >20 Days
NF to SCNF
E-ARC PAS
Medicare to Medicaid
Out of State Approval Admission
Other:
V.
ADMISSION INFORMATION
1. Admission Date:
/
/
/
/
2. Date of PAS, if applicable:
3. Admitted from:
Community/Boarding Home
Psychiatric Hospital
/
/
Private to Medicaid - Anticipated Medicaid Effective Date:
Hospital
Other LTCF
Other
(specify):
/
/
4. Name of Hospital/LTCF:
Admission Date:
Address:
5. If admitted from Hospital/LTCF, give the name/address of previous residence (Hospital Name and Address or Home Address):
VI. TERMINATION INFORMATION
/
/
1. Discharge Date:
2. Discharged to:
Home-Community (including relative’s home)/ County of residence:
County of NF:
Facility Name:
County of Residence:
Other (specify):
Telephone Number of Discharge Site:
/
/
3. Death (Date):
In LTCF
In Hospital
VII. CERTIFICATION:
The facility certifies that the patient will reside only in those areas of the facility which are certified for
participation in the New Jersey Medicaid Program at the level of care authorized for this patient by the New Jersey Medicaid Program.
The facility also certifies that upon discharge to a hospital, the patient’s room/bed will be reserved for the full period of time covered
by the New Jersey Medicaid Bed Reserve Policy. If nursing facility bills Medicaid for long term care services, the person signing this form
certifies that the facility has a valid PAS on file. This form completed by:
Phone Number:
Name:
Date:
Title:
VIII. CWA USE ONLY
/
/
Medicaid Effective Date:
Medicaid ONLY (PR-1 Attached)
COUNTY WELFARE OFFICE
SSI Only (PR-1 Required, Contact DHS)
Street Address:
Not Eligible
/
/
Transcript Requested - Date:
City and Zip:
Remarks:
Name of Case Worker:
Date:
LTC-2
JUL 14
Original-CWA
Copy-OCCO RO
Copy-Provider