Form LTC-4 "Referral for Onsite Occo Clinical Assessment" - New Jersey

What Is Form LTC-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 September 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 LTC-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 LTC-4 "Referral for Onsite Occo Clinical Assessment" - New Jersey

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New Jersey Department of Human Services
Division of Aging Services
Office of Community Choice Options
Referral for Onsite OCCO Clinical Assessment
Traditional/Acute
Acute Rehab (LTAC)
Psychiatric -
:
Type of Hospital:
Identify type
Long-term or
Short-term
PLEASE PRINT
Hospital:
Date:
Referred By:
Telephone #:
Provider/Referent Email:
PATIENT INFORMATION
Name:
DOB:
(Last)
(First)
(MI)
Sex
Male
Female
Medicaid #:
SS#:
Home Address:
Responsible Party:
(
)
(
)
Home Telephone No.:
Work Telephone No.:
HOSPITAL ADMISSION INFORMATION
Date of Admission:
Floor:
Admitted From:
Room #:
Primary Admitting Diagnosis:
Secondary Admitting Diagnosis:
PASRR
PASRR Level I Screen Outcome:
Positive
Negative
N/A
Date:
(d/c other than NF)
Does not require specialized services
If positive, PASRR Level II Determination:
Date:
Does require specialized services
Date:
Important: If being discharged to NF and the PASRR Level I is Positive, a copy of PASRR Level I, as well as the Level II Evaluation and
Determination must accompany this form.
A new PASRR Level II Evaluation and Determination is required for all instances of a discharge from any type of psychiatric
hospital prior to NF transfer, and a copy of the determination must accompany this form.
DISCHARGE PLAN
(Required for all referrals from Psychiatric settings)
Anticipated Discharge Date:
Expected Location:
Nursing Facility
ALR
CRS
Home
SCNF
:
Other:
(type)
Discharge Location Name and Address (if known):
Same as residential address identified above
MEDICAID ELIGIBILITY STATUS
Currently Medicaid Eligible
Date Referred to CWA:
Application in Process
180 Days Potentially Eligible
LTC-4
SEP 19
New Jersey Department of Human Services
Division of Aging Services
Office of Community Choice Options
Referral for Onsite OCCO Clinical Assessment
Traditional/Acute
Acute Rehab (LTAC)
Psychiatric -
:
Type of Hospital:
Identify type
Long-term or
Short-term
PLEASE PRINT
Hospital:
Date:
Referred By:
Telephone #:
Provider/Referent Email:
PATIENT INFORMATION
Name:
DOB:
(Last)
(First)
(MI)
Sex
Male
Female
Medicaid #:
SS#:
Home Address:
Responsible Party:
(
)
(
)
Home Telephone No.:
Work Telephone No.:
HOSPITAL ADMISSION INFORMATION
Date of Admission:
Floor:
Admitted From:
Room #:
Primary Admitting Diagnosis:
Secondary Admitting Diagnosis:
PASRR
PASRR Level I Screen Outcome:
Positive
Negative
N/A
Date:
(d/c other than NF)
Does not require specialized services
If positive, PASRR Level II Determination:
Date:
Does require specialized services
Date:
Important: If being discharged to NF and the PASRR Level I is Positive, a copy of PASRR Level I, as well as the Level II Evaluation and
Determination must accompany this form.
A new PASRR Level II Evaluation and Determination is required for all instances of a discharge from any type of psychiatric
hospital prior to NF transfer, and a copy of the determination must accompany this form.
DISCHARGE PLAN
(Required for all referrals from Psychiatric settings)
Anticipated Discharge Date:
Expected Location:
Nursing Facility
ALR
CRS
Home
SCNF
:
Other:
(type)
Discharge Location Name and Address (if known):
Same as residential address identified above
MEDICAID ELIGIBILITY STATUS
Currently Medicaid Eligible
Date Referred to CWA:
Application in Process
180 Days Potentially Eligible
LTC-4
SEP 19