Form LTC-37 "Assisted Living Facility - Provider Enrollment Statement of Intent to Accept Room and Board (R&b) Supplementation" - New Jersey

What Is Form LTC-37?

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, 2015;
  • 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-37 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-37 "Assisted Living Facility - Provider Enrollment Statement of Intent to Accept Room and Board (R&b) Supplementation" - New Jersey

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New Jersey Department of Human Services
Division of Aging Services
Medicaid Waiver
P.O. Box 807
Trenton, NJ 08625-0807
ASSISTED LIVING (AL) FACILITY – PROVIDER ENROLLMENT
STATEMENT OF INTENT TO ACCEPT ROOM AND BOARD (R&B) SUPPLEMENTATION
Name of Assisted Living (AL) Facility
Address of AL Facility
Medicaid Provider Number
Telephone Number
Describe the AL Facility Unit(s) designated for Medicaid Waiver Participants:
Attach a copy of the Assisted Living facility’s current fee schedule. If the Medicaid Unit is typically a
shared or companion Unit, the published fee schedule must show the baseline rate that each person is
charged for the Unit.
Please note:
 A new fee schedule must be sent to Quality Assurance Unit (QAU) each time the AL Facility’s
Unit rate(s) change.
 An LTC-37 form is submitted one time only; it is not necessary to include another copy when
submitting an LTC-38: Room and Board Supplementation Notification for each individual
Medicaid Waiver participant and his or her participating third party-payor.
 Room and Board Supplementation amount is in addition to the customary Room and Board fee
paid to the AL directly by the Medicaid participant.
Name of AL Facility Representative
Title
Signature
Date
Once submitted, a representative from QAU will contact you to
approve this Statement of Intent to accept Room and Board Supplementation.
LTC-37
OCT 15
New Jersey Department of Human Services
Division of Aging Services
Medicaid Waiver
P.O. Box 807
Trenton, NJ 08625-0807
ASSISTED LIVING (AL) FACILITY – PROVIDER ENROLLMENT
STATEMENT OF INTENT TO ACCEPT ROOM AND BOARD (R&B) SUPPLEMENTATION
Name of Assisted Living (AL) Facility
Address of AL Facility
Medicaid Provider Number
Telephone Number
Describe the AL Facility Unit(s) designated for Medicaid Waiver Participants:
Attach a copy of the Assisted Living facility’s current fee schedule. If the Medicaid Unit is typically a
shared or companion Unit, the published fee schedule must show the baseline rate that each person is
charged for the Unit.
Please note:
 A new fee schedule must be sent to Quality Assurance Unit (QAU) each time the AL Facility’s
Unit rate(s) change.
 An LTC-37 form is submitted one time only; it is not necessary to include another copy when
submitting an LTC-38: Room and Board Supplementation Notification for each individual
Medicaid Waiver participant and his or her participating third party-payor.
 Room and Board Supplementation amount is in addition to the customary Room and Board fee
paid to the AL directly by the Medicaid participant.
Name of AL Facility Representative
Title
Signature
Date
Once submitted, a representative from QAU will contact you to
approve this Statement of Intent to accept Room and Board Supplementation.
LTC-37
OCT 15