Get Client Funding Utilization - State Of New Jersey - State Nj

Completing the Client Funding Utilization form online is a crucial step for accessing funding for adult day services in New Jersey. This guide will provide clear instructions on filling out each section of the form accurately to ensure a smooth submission process.

Follow the steps to complete the Client Funding Utilization form effectively.

1. Click the ‘Get Form’ button to obtain the form and open it in an online editor.
2. Enter the name of the agency in the designated field at the top of the form.
3. Fill in the name of the client as requested. Ensure accuracy to avoid any issues with processing.
4. Provide the client's Social Security Number in the specified box. This is important for identification purposes.
5. Complete the client's street address, city, state, and zip code accurately to ensure proper communication.
6. In section A, enter the total adjusted income of the client or the client and their partner, as required.
7. Input the per diem reimbursement amount provided by NJDHS Alzheimer's Adult Day Services in section B.
8. In section C, indicate the co-payment to be assessed per unit of service based on the client's funding plan.
9. Fill in the start or renewal date for Alzheimer's Adult Day Services funding in section D.
10. In section E, specify the weekly units (days) of service provided through various funding sources including Medicaid, MLTSS, and others. Be sure to check all applicable options.
11. If choosing to pay privately, indicate that clearly, and tally the total weekly units in the provided field.
12. Confirm your agreement with the co-payment rate by signing where indicated as the primary caregiver.
13. Include the date of the signature beside the signature field.
14. An agency representative must review the payment plan with the client's caregiver, providing their name, title, and signature along with the date.
15. After completing the form, save any changes made, and ensure to download, print, or share the form as necessary for submission.

Complete your forms online today to expedite your funding request process.