New Jersey Department of Human Services

Division of Aging Services

SPECIAL REQUEST

1.	Name of Participant

2.	Date

3.	JACC No.

4.	Name of Care Manager

5.	Care Manager Telephone Number

6.	Name of Care Management Agency

7.	County

8. Current Authorized Services	9. Special Request Type (check as applicable)
Adult Day Health Services (ADHS)

Attendant Care

Caregiver/Recipient Training

Care Management

Chore Service

Environmental Accessibility Adaptations (EAA)

Home-Based Supportive Care (HBSC)

Home-Delivered Meal

PERS

Respite

Social Adult Day Care (SADC)

Special Medical Equipment and Supplies (SME)

Transportation	JACC
Prior Approval	Exception
Chore Service

Environmental Accessibility Adaptations (EAA)

Special Medical Equipment and Supplies (SME)	ADHS

Home-Based Supportive Care (HBSC)

Respite

Transportation

Total Monthly service budget exceed $600 per month.
10. Is the Home Care agency for the exceptions request in #9 accredited yes no

11.	Special Request Justification - The narrative to support the reasons for this request are to address the following areas:
A.	What are the reasons for making this request? Be specific and thorough. Include the item or service being requested and the name of the provider. For Respite Requests, indicate whether it will be in-home or in-facility. For in-home respite, a back‑up plan must be included.

B.	How does the item/service requested meet the particular needs of the participant involved? Include any relevant factors about the client’s age, diagnosis, activities of daily living functioning, and informal support systems.

C.	What is the expected duration of the conditions prompting this request? For Respite Requests, include the date range and number of days being requested.

D.	What other alternatives have been explored, and with what result?

E.	If not granted, what will be the result for the participant?

12.	Has this participant had any previous JACC Special Requests approved within this State fiscal year?

No Yes, Specify:	13.	Cost of this Request (For Respite Requests, indicate the per diem, along with the total.)

$

14.	Will the costs be maintained/amortized within the participant’s annual service cap?

No Yes	15.	Current Monthly Authorized Cost

$	16.	Monthly Authorized Cost, if Request Granted

$

Name of Care Manager (CM)

Signature

Date

Name of Care Coordinator/CM Supervisor

Signature

Date

Use additional sheets as necessary and attach estimates, literature, or any other supporting documentation.

SPECIAL REQUEST

(Continued)

CP-10 (GO 491)

JUL 12	-2-

CP-10

AUG 16

CP-10, Special Request

CP-10, GO 491, Special Request, JACC, CAP, ACS, Aging

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2016-08-03

human services