Form WPA-8 "Individual Service Agreement" - New Jersey

What Is Form WPA-8?

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 October 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;

Download a printable version of Form WPA-8 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 WPA-8 "Individual Service Agreement" - New Jersey

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New Jersey Department of Human Services
INDIVIDUAL SERVICE AGREEMENT
1.
Service
Start:
Revise:
Stop:
Effective Date
Effective Date
Effective Date
2.
Participant:
3.
ID Number:
4.
Address:
5.
Telephone No.:
6.
Date of Birth:
7.
Program:
JACC
Other (specify):
8.
Care Manager No.:
The following service has been authorized for the above client according to the schedule and cost shown.
Service
9.
Service name
10.
Code
Initial
Revise
11.
Unit of Service
12.
Units per Visit
13.
Frequency of Service
14.
Total Units per Week
15.
Authorized Cost per Unit
16.
Authorized Cost per Week
17.
Authorized Cost per Month (weekly cost X 4.33)
18. Specifications:
Provider:
DHS will pay only for those services authorized
and provided pursuant to program rules.
This notice confirms arrangements for services
19.
Stop Services - Reason:
made by the Care Manager. You must submit an
invoice at the conclusion of service or end of each
month of service.
If there is a change in the participant's condition,
20.
Resume Services - Date:
contact the Care Manager immediately.
Contact the Care Manager if you note errors in the
above information or if you have any questions.
21.
Other - Specify:
22. Provider Name
23. Provider EIN No.
24. Provider Signature and Title (Optional for Traditional and Non-Traditional Providers)
Date
25. Care Manager’s Name and Title
Date
Flow: 1.
Authorizing Care Manager completes, signs, and sends to Service Provider.
2.
Care Coordinator forwards to DoAS Billing Agent.
WPA-8
3.
ADHS Provider is required to sign on Line 24 and returns to Care Manager.
OCT 14
4.
ADHS Provider sends copy of this form with PA request to ADHS Central Office.
New Jersey Department of Human Services
INDIVIDUAL SERVICE AGREEMENT
1.
Service
Start:
Revise:
Stop:
Effective Date
Effective Date
Effective Date
2.
Participant:
3.
ID Number:
4.
Address:
5.
Telephone No.:
6.
Date of Birth:
7.
Program:
JACC
Other (specify):
8.
Care Manager No.:
The following service has been authorized for the above client according to the schedule and cost shown.
Service
9.
Service name
10.
Code
Initial
Revise
11.
Unit of Service
12.
Units per Visit
13.
Frequency of Service
14.
Total Units per Week
15.
Authorized Cost per Unit
16.
Authorized Cost per Week
17.
Authorized Cost per Month (weekly cost X 4.33)
18. Specifications:
Provider:
DHS will pay only for those services authorized
and provided pursuant to program rules.
This notice confirms arrangements for services
19.
Stop Services - Reason:
made by the Care Manager. You must submit an
invoice at the conclusion of service or end of each
month of service.
If there is a change in the participant's condition,
20.
Resume Services - Date:
contact the Care Manager immediately.
Contact the Care Manager if you note errors in the
above information or if you have any questions.
21.
Other - Specify:
22. Provider Name
23. Provider EIN No.
24. Provider Signature and Title (Optional for Traditional and Non-Traditional Providers)
Date
25. Care Manager’s Name and Title
Date
Flow: 1.
Authorizing Care Manager completes, signs, and sends to Service Provider.
2.
Care Coordinator forwards to DoAS Billing Agent.
WPA-8
3.
ADHS Provider is required to sign on Line 24 and returns to Care Manager.
OCT 14
4.
ADHS Provider sends copy of this form with PA request to ADHS Central Office.