Form Ltc 2 – Fill Out and Use This PDF

Form Ltc 2 is a beneficial program for organizations that are looking for an effective way to manage their long-term care insurance needs. It enables them to provide quality services for elderly or disabled beneficiaries by facilitating access to information and assistance throughout their entire process of caring for such individuals. In addition, the program provides assurance of the financial wellbeing of long term care respondents from inception to discharge. By finding optimal payment strategies while assessing beneficiary needs, Form Ltc 2 allows organizations to more easily comply with regulations on restricted compensation structures. Utilizing its specialized pricing solutions, discounts and cost controls are readily identified which help protect against unanticipated repair costs associated with claim transfers. Furthermore, it helps organization to better manage care needs across the continuum at various locations regardless of complexity.

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Question	Answer
Form Name	Form Ltc 2
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	CWA, pasrr level 2 nj, nj pasrr level ii determination letter sample, SSI

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New Jersey Department of Health and Senior Services	Type
Division of Aging and Community Services	Request PAS
NOTIFICATION FROM LONG-TERM CARE FACILITY	Notice of Admission
OF ADMISSION OR TERMINATION OF A MEDICAID BENEFICIARY	Notice of Termination

I.PATIENT INFORMATION

Name:

2. Social Security No.:

(LAST)

(FIRST)

HSP (Medicaid) Case No.:

Date of Birth:

Confirmed By (CWA):

Medicaid Only

SSI

5. Sex:

Female

Male

II.PROVIDER INFORMATION


1.	Provider Number:	5.		Provider Phone #:
2.	LTCF Name:		6.	SCNF:

3.Address:

4.City, State, Zip:

III. REQUEST FOR PAS

Private to Medicaid PASRR Exempt >30 Days PAS Exempt >20 Days Hospice Revoked

Medicaid Managed Care Terminated

ARC PAS

Out of State Approval Admission

Other:

Date of Level I PASSR:


Positive		Negative

IV.

ADMISSION INFORMATION

Admission Date:

Date of PAS, if applicable:

Track 1

Track 2

E-ARC PAS

Admitted from:

Community/Boarding Home

Medicare to Medicaid

Psychiatric Hospital

Private to Medicaid - anticipated Medicaid effective date:

Hospital

Other LTCF

Other (specify):

Name of Hospital/LTCF:

Admission Date:

Address:

If admitted from Hospital/LTCF, give the name/address of previous residence (Hospital Name and Address or Home Address):

V.TERMINATION INFORMATION

Discharge Date:

Discharged to:

Home-Community (including relative’s home)/ County of residence:

Facility Name:

County of NF:

Other (specify):

County of residence:

Telephone Number of Discharge Site

Death (Date):

In LTCF

In Hospital

VI. CERTIFICATION

The facility certifies that the patient will reside only in those areas of the facility which are certified for participation in the New Jersey Medicaid Program at the level of care authorized for this patient by the New Jersey Medicaid Program. The facility also certifies that upon discharge to a hospital, the patient’s room/bed will be reserved for the full period of time covered by the New Jersey Medicaid Bed Reserve Policy. If nursing facility bills Medicaid for long term care services, the person signing this form certifies that the facility has a valid PAS on file.

This form completed by:

Name:

Phone Number:

Title:

Date:

VII. CWA USE ONLY

Medicaid Effective Date:

Medicaid ONLY (PA-3L Attached)

COUNTY WELFARE OFFICE

SSI Only (PA-3L Required, Contact DHSS)

Street Address:

Not Eligible

Transcript Requested - Date:

City and Zip:

Remarks:

Name of Case Worker:

Date:

LTC-2
AUG 11	Original-CWA	Copy-LTCFO	Copy-Provider

Form Ltc 2 – Fill Out and Use This PDF

Form Ltc 2 PDF Details

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