Form JACC-8 Section III "Homecare Services Provider Qualifications" - New Jersey

What Is Form JACC-8 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 July 1, 2019;
  • 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-8 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-8 Section III "Homecare Services Provider Qualifications" - New Jersey

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New Jersey Department of Human Services
Division of Aging Services
Provider Application Section III: Services
HOMECARE SERVICES
Read carefully the description of services and requirements.
If you do not qualify, please do not apply.
Definition:
Homecare Services includes assistance with eating, bathing, dressing, personal
hygiene, and the activities of daily living. This service may include assistance with
preparation of meals, but does not include the cost of the meals themselves. When
specified in the plan of care, this service may also include such housekeeping chores as
bed-making, dusting, and vacuuming, which are incidental to the care furnished, or
which are essential to the health and welfare of the individual, rather than the
individual’s family. Homecare providers must meet state standards for this service.
Billing Codes:
JACC
Service/Unit
Rates Per Unit
Limitations
J1200
1 hour weekday
$18.00
Per ISA
weekend or holiday
J1205
RN initial assessment
$35.00
Per ISA, initial only
J1290
RN reassessment
$35.00
Per ISA
JACC-8
JUL 19
New Jersey Department of Human Services
Division of Aging Services
Provider Application Section III: Services
HOMECARE SERVICES
Read carefully the description of services and requirements.
If you do not qualify, please do not apply.
Definition:
Homecare Services includes assistance with eating, bathing, dressing, personal
hygiene, and the activities of daily living. This service may include assistance with
preparation of meals, but does not include the cost of the meals themselves. When
specified in the plan of care, this service may also include such housekeeping chores as
bed-making, dusting, and vacuuming, which are incidental to the care furnished, or
which are essential to the health and welfare of the individual, rather than the
individual’s family. Homecare providers must meet state standards for this service.
Billing Codes:
JACC
Service/Unit
Rates Per Unit
Limitations
J1200
1 hour weekday
$18.00
Per ISA
weekend or holiday
J1205
RN initial assessment
$35.00
Per ISA, initial only
J1290
RN reassessment
$35.00
Per ISA
JACC-8
JUL 19
HOMECARE 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 1
1.a
Medicare Certified Home Health Agency licensed by NJ DOH, per N.J.A.C.
8:42*
Evidence of Liability Insurance and Worker’s Compensation Coverage
1.b
Section 2
2.a
Homecare Agency with Health Care Service Firm License from the
NJ DL&PS, per N.J.A.C.13:45B*
2.b
Accredited by National Home Caring Council, Commission on Accreditation
for Home Care Inc., The Joint Commission and/or the Community Health
Accreditation Program
Evidence of Liability Insurance and Worker’s Compensation Coverage
2.c
*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 IS
,
,
. I
TRUE
ACCURATE
AND COMPLETE
AM AWARE THAT IF ANY OF THE STATEMENTS MADE BY ME IN THIS APPLICATION
, I
,
ARE WILLFULLY FALSE
AM SUBJECT TO PUNISHMENT
INCLUDING BUT NOT LIMITED TO DISQUALIFICATION FROM THE
N
J
JACC P
. I
J
D
H
S
,
EW
ERSEY
ROGRAM
AGREE TO NOTIFY THE NEW
ERSEY
EPARTMENT OF
UMAN
ERVICES
D
A
S
.
IVISION OF
GING
ERVICES OF ANY CHANGES IN THE INFORMATION CONTAINED IN THIS APPLICATION
Name and Title of Applicant
Representative____________________________________________
Signature____________________________________ Date____________
JACC-8
JUL 19
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