Form JACC-5 "Jacc Provider Application, Section Iii: Environmental Accessibility Adaption" - New Jersey

What Is Form JACC-5?

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 March 1, 2020;
  • The latest edition provided by the New Jersey Department of Human Services;
  • Easy to use and ready to print;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form JACC-5 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-5 "Jacc Provider Application, Section Iii: Environmental Accessibility Adaption" - New Jersey

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New Jersey Department of Human Services
Division of Aging Services
Provider Application Section III: Services
ENVIRONMENTAL ACCESSIBILITY ADAPTION
Read carefully the description of services and requirements.
If you do not qualify, please do not apply.
Definition:
Those physical adaptations to the home, required by the individual's plan of care, which
are necessary to ensure the health, welfare and safety of the individual, or which enable
the individual to function with greater independence in the home and without which the
individual would require institutionalization.
Such adaptations may include the installation of ramps and grab-bars, widening of
doorways, modification of bathroom facilities, or installation of specialized electric and
plumbing systems, which are necessary to accommodate the medical equipment and
supplies that are necessary for the welfare of the individual.
Excluded are those adaptations or improvements to the home that are of general utility,
and are not of direct medical or remedial benefit to the individual, such as carpeting,
roof repair, central air conditioning, etc. Adaptations that add to the total square footage
of the home are excluded from this benefit.
All services shall be provided in accordance with applicable State or local building
codes. Evidence of permits and approval must be available as required.
The EAA Provider must:
 Conduct an on-site visit with the care manager and JACC participant at the home
to ensure repairs are necessary, are completed to satisfaction, and meet housing
codes.
 Ensure permits are acquired if needed.
 Plan, schedule, inspect and monitor the assigned repair work.
 Ensure all services are provided in accordance with applicable State, Local and
Americans with Disability Act (ADA) and/or ADA Accessibility Guidelines
(ADAAG) and Specifications.
 Authorization of final payment for repairs/replacement to the contractor will only
occur upon project completion and satisfaction of the consumer and care
manager.
Billing Codes:
JACC
Service/Unit
Rates Per Unit
J9795
1 Job
Usual and Customary Charge
JACC-5
MAR 20
New Jersey Department of Human Services
Division of Aging Services
Provider Application Section III: Services
ENVIRONMENTAL ACCESSIBILITY ADAPTION
Read carefully the description of services and requirements.
If you do not qualify, please do not apply.
Definition:
Those physical adaptations to the home, required by the individual's plan of care, which
are necessary to ensure the health, welfare and safety of the individual, or which enable
the individual to function with greater independence in the home and without which the
individual would require institutionalization.
Such adaptations may include the installation of ramps and grab-bars, widening of
doorways, modification of bathroom facilities, or installation of specialized electric and
plumbing systems, which are necessary to accommodate the medical equipment and
supplies that are necessary for the welfare of the individual.
Excluded are those adaptations or improvements to the home that are of general utility,
and are not of direct medical or remedial benefit to the individual, such as carpeting,
roof repair, central air conditioning, etc. Adaptations that add to the total square footage
of the home are excluded from this benefit.
All services shall be provided in accordance with applicable State or local building
codes. Evidence of permits and approval must be available as required.
The EAA Provider must:
 Conduct an on-site visit with the care manager and JACC participant at the home
to ensure repairs are necessary, are completed to satisfaction, and meet housing
codes.
 Ensure permits are acquired if needed.
 Plan, schedule, inspect and monitor the assigned repair work.
 Ensure all services are provided in accordance with applicable State, Local and
Americans with Disability Act (ADA) and/or ADA Accessibility Guidelines
(ADAAG) and Specifications.
 Authorization of final payment for repairs/replacement to the contractor will only
occur upon project completion and satisfaction of the consumer and care
manager.
Billing Codes:
JACC
Service/Unit
Rates Per Unit
J9795
1 Job
Usual and Customary Charge
JACC-5
MAR 20
ENVIRONMENTAL ACCESSIBILITY ADAPTION 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 or Trade Name Registration
1.b
Any license required by law to engage in the service (i.e. Master Plumbers,
general contractor, etc.)
Evidence of Liability Insurance and Worker’s Compensation Coverage
1.c
1.d
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 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-5
MAR 20
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