Form JACC-4 Section III "Jacc Provider Application: Chore Services" - New Jersey

What Is Form JACC-4 Section III?

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 November 1, 2016;
  • 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 JACC-4 Section III 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 JACC-4 Section III "Jacc Provider Application: Chore Services" - New Jersey

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New Jersey Department of Human Services
Division of Aging Services
Provider Application Section III: Services
CHORE SERVICES
Read carefully the description of services and requirements.
If you do not qualify, please do not apply.
Definition:
Services needed to maintain the home in a clean, sanitary and safe environment. This
service includes heavy household chores such as washing floors, windows and walls,
tacking down loose rugs and tiles, moving heavy items of furniture in order to provide
safe access and egress. These services will be provided only in cases where neither
the individual, nor anyone else in the household, is able of performing or financially
providing for them, and where no other relative, caregiver, landlord,
community/volunteer agency, or third party payer is capable of or responsible for their
provision. In the case of rental property, the responsibility of the landlord, pursuant to
the lease agreement, will be examined prior to any authorization of service.
Chores are non-continuous, non-routine household maintenance tasks intended to
increase the safety of the individual.
Services Include:
 Cleaning appliances
 Cleaning and securing rugs and carpets
 Washing wall, windows, and scrubbing floors
 Cleaning attics and basements to remove fire and health hazards
 Clearing walkways of ice, snow, leaves
 Trimming overhanging tree branches
 Replacing fuses, light bulbs, electric plugs, frayed cords
 Replacing door locks, window catches
 Replacing faucet washers
 Installing safety equipment
 Seasonal changes of screens and storm windows
 Weather stripping around doors
 Caulking windows
Billing Codes:
JACC
Service/Unit
Rates Per Unit
J9838
1 Job
Usual and Customary Charge
JACC-4
NOV 16
New Jersey Department of Human Services
Division of Aging Services
Provider Application Section III: Services
CHORE SERVICES
Read carefully the description of services and requirements.
If you do not qualify, please do not apply.
Definition:
Services needed to maintain the home in a clean, sanitary and safe environment. This
service includes heavy household chores such as washing floors, windows and walls,
tacking down loose rugs and tiles, moving heavy items of furniture in order to provide
safe access and egress. These services will be provided only in cases where neither
the individual, nor anyone else in the household, is able of performing or financially
providing for them, and where no other relative, caregiver, landlord,
community/volunteer agency, or third party payer is capable of or responsible for their
provision. In the case of rental property, the responsibility of the landlord, pursuant to
the lease agreement, will be examined prior to any authorization of service.
Chores are non-continuous, non-routine household maintenance tasks intended to
increase the safety of the individual.
Services Include:
 Cleaning appliances
 Cleaning and securing rugs and carpets
 Washing wall, windows, and scrubbing floors
 Cleaning attics and basements to remove fire and health hazards
 Clearing walkways of ice, snow, leaves
 Trimming overhanging tree branches
 Replacing fuses, light bulbs, electric plugs, frayed cords
 Replacing door locks, window catches
 Replacing faucet washers
 Installing safety equipment
 Seasonal changes of screens and storm windows
 Weather stripping around doors
 Caulking windows
Billing Codes:
JACC
Service/Unit
Rates Per Unit
J9838
1 Job
Usual and Customary Charge
JACC-4
NOV 16
CHORE SERVICES PROVIDER QUALIFICATIONS
The applicant must submit evidence that it meets all items within the following
section(s).
Please check off ONE section in which you are applying
Section 1☐
Section 1
1.a
Business entity with evidence of authority to conduct such business in NJ,
i.e. NJ Tax Certificate, Trade Name Registration and/or Ownership proof
1.b
Any license required by law to engage in the service, provide equipment,
etc.
1.c
Business product/service literature
Evidence of Liability Insurance and Worker’s Compensation Coverage
1.d
1.e
Fee Schedule
Check all evidence submitted with application.
Incomplete applications and / or applications submitted without required
documentation and evidence will be returned.
CERTIFICATION
F
OR THE PURPOSE OF ESTABLISHING ELIGIBILITY TO RECEIVE DIRECT PAYMENT FOR SERVICES TO RECIPIENTS
N
J
JACC P
, I
UNDER THE
EW
ERSEY
ROGRAM
CERTIFY THAT THE INFORMATION FURNISHED ON THIS APPLICATION
,
,
. I
IS TRUE
ACCURATE
AND COMPLETE
AM AWARE THAT IF ANY OF THE STATEMENTS MADE BY ME IN THIS
, I
,
APPLICATION ARE WILLFULLY FALSE
AM SUBJECT TO PUNISHMENT
INCLUDING BUT NOT LIMITED TO
N
J
JACC P
. I
J
D
DISQUALIFICATION FROM THE
EW
ERSEY
ROGRAM
AGREE TO NOTIFY THE NEW
ERSEY
EPARTMENT
H
S
, D
A
S
OF
UMAN
ERVICES
IVISION OF
GING
ERVICES OF ANY CHANGES IN THE INFORMATION CONTAINED IN THIS
.
APPLICATION
Name and Title of Applicant
Representative____________________________________________
Signature____________________________________ Date____________
JACC-4
NOV 16
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