New Jersey Department of Human Services

Adult Day Services Program for

Persons with Alzheimer's Disease or Related Disorders

PO Box 807

Trenton, NJ 08625-0807	DISCHARGE INFORMATION
Name of Agency

Name of Client

Social Security Number

1.	Reason for Client's Discharge from Program (Check up to 3)	(1)
00 Dementia Progression
01 Other Illness/Accident
02 Incontinence
03 Inappropriate Behavior
04 Extended Absence
05 Financial Ineligibility
06 Relocation
07 Client Refusal to Attend
08 Death
09 Other (Specify):
10 Family Choice
11 Caregiver Illness/Stress
12 Caregiver Death
Transfer to Other Funding Source:
13 Medicaid
14 MLTSS
15 Peer Grouping
16 Respite
17 SSBG
18 Jersey Care
19 JACC
2.	Duration of Day Care Attendance	(2)
00 0 - 3 Months
01 3 - 6 Months
02 6 - 12 Months
03 1 - 2 Years
04 2 - 5 Years
05 Over 5 Years
06 Ongoing
3.	Client Was Discharged To:	(3)
00 Home
01 Assisted Living Facility
02 Residential Health Care Facility
03 Long Term Care Facility
04 Acute Care Hospital
05 Not Applicable
06 Other Day Care
4.	Last Date Client Received Alzheimer's Adult Day Care Funds	(4)	/	/
(Month/Day/Year)	/	/
5.	Total Alzheimer's Adult Day Care Funds Billed to
DHS for Client's Care During Current Fiscal Year:	(5)	$
$
Name of Agency Representative

Title

Signature	Date

CSS-9

OCT 14	Distribution: Original - NJDHS Copy - Agency

CSS-9, Discharge Information

css-9, aging services, DAS, discharge information

2004-07-06

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human services