Form JACC-6 Section III "Jacc Provider Application: Facility-Based Respite Care Services" - New Jersey

What Is Form JACC-6 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-6 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-6 Section III "Jacc Provider Application: Facility-Based Respite Care Services" - New Jersey

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New Jersey Department of Human Services
Division of Aging Services
Provider Application Section III: Services
FACILITY-BASED RESPITE CARE SERVICES
Read carefully the description of services and requirements.
If you do not qualify, please do not apply.
Definition:
Services provided to individuals unable to care for themselves; furnished on a short-
term basis because of the absence or need for relief of those persons normally
providing the care.
Other service Definition (Specify): FFP (Federal Financial Participation) will not be
claimed for the cost of room and board except when provided as part of respite care
furnished in a facility approved by the State that is not a private residence.
Service Limitations/Exclusions Include:
 FFP will not be claimed for the cost of room and board except when provided,
as part of respite care furnished in a facility approved by the State that is not
a private residence.
 Room and board charges are included in Institutional Respite rate.
 Respite in a Medicaid certified Nursing Facility is limited to 30 days per
recipient per waiver year.
Billing Codes:
JACC
Service/Unit
J1285
Nursing Facility Respite
Assisted Living residence Respite
Adult Family Care Respite
Comprehensive Personal Care Home Respite
JACC-6
NOV 16
New Jersey Department of Human Services
Division of Aging Services
Provider Application Section III: Services
FACILITY-BASED RESPITE CARE SERVICES
Read carefully the description of services and requirements.
If you do not qualify, please do not apply.
Definition:
Services provided to individuals unable to care for themselves; furnished on a short-
term basis because of the absence or need for relief of those persons normally
providing the care.
Other service Definition (Specify): FFP (Federal Financial Participation) will not be
claimed for the cost of room and board except when provided as part of respite care
furnished in a facility approved by the State that is not a private residence.
Service Limitations/Exclusions Include:
 FFP will not be claimed for the cost of room and board except when provided,
as part of respite care furnished in a facility approved by the State that is not
a private residence.
 Room and board charges are included in Institutional Respite rate.
 Respite in a Medicaid certified Nursing Facility is limited to 30 days per
recipient per waiver year.
Billing Codes:
JACC
Service/Unit
J1285
Nursing Facility Respite
Assisted Living residence Respite
Adult Family Care Respite
Comprehensive Personal Care Home Respite
JACC-6
NOV 16
FACILITY-BASED RESPITE CARE 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 2☐
Section 3☐
Section 1
1.a
Assisted Living Residences or Assisted Living Programs or Comprehensive
Personal Care Homes, licensed by NJ DOH, per N.J.A.C. 8:36*
1.b
Medicaid Provider # _______________________
Section 2
2.a
Adult Family Care Providers licensed by NJ DOH, per N.J.A.C. 8:43B*
2.b
Medicaid Provider # _______________________
Section 3
3.a
Nursing Facilities licensed by NJ DOH, per N.J.A.C. 8:39*
3.b
Medicaid Provider # _______________________
*Submit photocopy as evidence.
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-6
NOV 16
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