Form ARR "Rehabilitative Hospital and Special Hospital Subject to a $10 Adjusted Admission Assessment" - New Jersey

What Is Form ARR?

This is a legal form that was released by the New Jersey Department of Health - 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 April 1, 2019;
  • The latest edition provided by the New Jersey Department of Health;
  • 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 fillable version of Form ARR by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form ARR "Rehabilitative Hospital and Special Hospital Subject to a $10 Adjusted Admission Assessment" - New Jersey

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New Jersey Department of Health
Hospital:
License Number:
REHABILITATIVE & SPECIAL HOSPITALS
Calendar Year:
ADMISSIONS & REVENUE REPORT
Revenue
Admissions
Total
2,3
2,3
Inpatient
Outpatient
SNF
MICU
4
SNF
OTHERS
SNRPC
(Skilled Nursing
(Mobile Intensive
1,2,3
Admissions
(Skilled Nursing
(Services Not
Facility)
Care Unit)
Facility)
Related to Patient
Care)
1
Enter total admissions for Rehabilitative and Special Hospitals.
2
Must exclude all Same Day Surgery as defined in NJAC 8:31B-3.11.
3
Exclude patients transferred from other units within the Hospital for all services.
4
Refer to Financial Elements, NJAC 8:31B-4.16, 4.64 and 4.65 for items to be included, and attach itemized schedule.
Failure to report in accordance with state law and regulation may result in a daily penalty being assessed past the submission due date. (N.J.S.A. 26:2H-18.57;
N.J.A.C. 8:31B-1 et seq.; N.J.A.C. 8:43E-1 et seq.). Intentional misrepresentation or falsification of any information contained within this cost report may result
in civil and criminal penalties.
CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S)
I hereby certify that I have read the above statement and that I have examined the accompanying cost report form by the
(Provider Name)
(License Number)
for the cost report period commencing on
and concluding on
,
and that to the best of my knowledge and belief, it is true, correct and complete statement prepared from the books and records of the provider
in accordance with the applicable instructions, except as noted.
Name of Contact
Title of Contact
Telephone Number
Date
First / Middle / Last
Name of Responsible Official
Title of Responsible Official
Signature
ARR
APR 19
New Jersey Department of Health
Hospital:
License Number:
REHABILITATIVE & SPECIAL HOSPITALS
Calendar Year:
ADMISSIONS & REVENUE REPORT
Revenue
Admissions
Total
2,3
2,3
Inpatient
Outpatient
SNF
MICU
4
SNF
OTHERS
SNRPC
(Skilled Nursing
(Mobile Intensive
1,2,3
Admissions
(Skilled Nursing
(Services Not
Facility)
Care Unit)
Facility)
Related to Patient
Care)
1
Enter total admissions for Rehabilitative and Special Hospitals.
2
Must exclude all Same Day Surgery as defined in NJAC 8:31B-3.11.
3
Exclude patients transferred from other units within the Hospital for all services.
4
Refer to Financial Elements, NJAC 8:31B-4.16, 4.64 and 4.65 for items to be included, and attach itemized schedule.
Failure to report in accordance with state law and regulation may result in a daily penalty being assessed past the submission due date. (N.J.S.A. 26:2H-18.57;
N.J.A.C. 8:31B-1 et seq.; N.J.A.C. 8:43E-1 et seq.). Intentional misrepresentation or falsification of any information contained within this cost report may result
in civil and criminal penalties.
CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S)
I hereby certify that I have read the above statement and that I have examined the accompanying cost report form by the
(Provider Name)
(License Number)
for the cost report period commencing on
and concluding on
,
and that to the best of my knowledge and belief, it is true, correct and complete statement prepared from the books and records of the provider
in accordance with the applicable instructions, except as noted.
Name of Contact
Title of Contact
Telephone Number
Date
First / Middle / Last
Name of Responsible Official
Title of Responsible Official
Signature
ARR
APR 19