Form CP-4 "Pace Request for Waiver of Nursing Facility Level of Care Recertification" - New Jersey

What Is Form CP-4?

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 March 1, 2018;
  • 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-4 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-4 "Pace Request for Waiver of Nursing Facility Level of Care Recertification" - New Jersey

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New Jersey Department of Human Services (DHS)
Division of Aging Services (DoAS)
PACE Administration
PO Box 807
Trenton, NJ 08625-0807
PACE Request for Waiver of Nursing Facility Level of Care Recertification
To request a Waiver of Nursing Facility Level of Care Recertification, complete the information below
and submit all required documentation listed on the form to DoAS, at least 45 days prior to the last
annual recertification authorization date.
From (Name/Title):
PACE Organization:
Email Address:
Fax Number:
Telephone Number:
Date of Request:
Recertification Due Date:
Participant Name:
Date of Last Assessment:
DoAS will only initiate the review of this request when all of the following documentation has been
received. Omitting any information requested below will delay approval of the waiver request.
Justification summary from IDT
Diagnosis of chronic or disabling condition
Last comprehensive assessment by all relevant disciplines
Last 2 IDT care plans
Initial LOC assessment and updated LOC assessment
History and Physical
Physician and nursing progress notes
All specialty consultant notes (any discipline)
Social work notes
Diagnostic tests supporting request
Medication and treatment record
Other relevant documentation supporting the request
Above request is:
Authorized/Date:
Not Authorized/Date:
Name and Title of Reviewer:
Signature:
Date:
Telephone:
CP-4
MAR 18
New Jersey Department of Human Services (DHS)
Division of Aging Services (DoAS)
PACE Administration
PO Box 807
Trenton, NJ 08625-0807
PACE Request for Waiver of Nursing Facility Level of Care Recertification
To request a Waiver of Nursing Facility Level of Care Recertification, complete the information below
and submit all required documentation listed on the form to DoAS, at least 45 days prior to the last
annual recertification authorization date.
From (Name/Title):
PACE Organization:
Email Address:
Fax Number:
Telephone Number:
Date of Request:
Recertification Due Date:
Participant Name:
Date of Last Assessment:
DoAS will only initiate the review of this request when all of the following documentation has been
received. Omitting any information requested below will delay approval of the waiver request.
Justification summary from IDT
Diagnosis of chronic or disabling condition
Last comprehensive assessment by all relevant disciplines
Last 2 IDT care plans
Initial LOC assessment and updated LOC assessment
History and Physical
Physician and nursing progress notes
All specialty consultant notes (any discipline)
Social work notes
Diagnostic tests supporting request
Medication and treatment record
Other relevant documentation supporting the request
Above request is:
Authorized/Date:
Not Authorized/Date:
Name and Title of Reviewer:
Signature:
Date:
Telephone:
CP-4
MAR 18