Form LTC-38 "Assisted Living Facility Notification of Room and Board (R&b) Supplementation" - New Jersey

What Is Form LTC-38?

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-38 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-38 "Assisted Living Facility Notification of 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
NOTIFICATION OF ROOM AND BOARD (R&B) SUPPLEMENTATION
Submit within 15 days of effective date to:
Or FAX to the Quality Assurance Unit
(QAU) at:
New Jersey Department of Human Services
Division of Aging Services
(609) 588-7683
P.O. Box 807
Trenton, NJ 08625-0807
Name of Assisted Living (AL) Facility
Telephone Number
Name of AL Resident/Medicaid Participant
Medicaid Number
Admission Date
Effective Date of R&B Supplementation
Is a Medicaid unit available at this time?
agreement if after admission:
Yes
No
Unit to which upgraded, must match room designation on fee schedule:
Monthly cost of upgrade:
Consequence of Non-Payment:
Telephone Number
Name of Voluntary Third-Party Payer
Relationship
Address
Signature
Date
Name of AL Facility Representative
Title
Signature
Date
Once submitted, a representative from the Division will contact you within two weeks if there are
questions regarding this notification. Otherwise, the Notification of R&B Supplementation is acceptable.
c: CWA
Medicaid Participant File
LTC-38
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
NOTIFICATION OF ROOM AND BOARD (R&B) SUPPLEMENTATION
Submit within 15 days of effective date to:
Or FAX to the Quality Assurance Unit
(QAU) at:
New Jersey Department of Human Services
Division of Aging Services
(609) 588-7683
P.O. Box 807
Trenton, NJ 08625-0807
Name of Assisted Living (AL) Facility
Telephone Number
Name of AL Resident/Medicaid Participant
Medicaid Number
Admission Date
Effective Date of R&B Supplementation
Is a Medicaid unit available at this time?
agreement if after admission:
Yes
No
Unit to which upgraded, must match room designation on fee schedule:
Monthly cost of upgrade:
Consequence of Non-Payment:
Telephone Number
Name of Voluntary Third-Party Payer
Relationship
Address
Signature
Date
Name of AL Facility Representative
Title
Signature
Date
Once submitted, a representative from the Division will contact you within two weeks if there are
questions regarding this notification. Otherwise, the Notification of R&B Supplementation is acceptable.
c: CWA
Medicaid Participant File
LTC-38
OCT 15