New Jersey Department of Human Services

Division of Aging Services

Global Options for Long Term Care (GO) Medicaid Waiver

P.O. Box 807

Trenton, NJ 08625-0807

ASSISTED LIVING (AL) FACILITY – PROVIDER ENROLLMENT

STATEMENT OF INTENT TO ACCEPT ROOM AND BOARD (R&B) SUPPLEMENTATION

Name of Assisted Living (AL) Facility

Address of AL Facility

Medicaid Provider Number

Telephone Number

Describe the AL Facility Unit(s) designated for GO Medicaid Waiver Participants:

Attach a copy of the Assisted Living facility’s current fee schedule. If the Medicaid Unit is typically a shared or companion Unit, the published fee schedule must show the baseline rate that each person is charged for the Unit.

Please note:

A new fee schedule must be sent to Quality Assurance Unit (QAU) each time the AL Facility’s Unit rate(s) change.

An Appendix A form is submitted one time only; it is not necessary to include another copy when submitting an Appendix B: Room and Board Supplementation Notification for each individual GO Waiver participant and his or her participating third party-payor.

Room and Board Supplementation amount is in addition to the customary Room and Board fee paid to the AL directly by the Medicaid participant.
Name of AL Facility Representative

Title

Signature	Date

Once submitted, a representative from QAU will contact you to

approve this Statement of Intent to accept Room and Board Supplementation.

Appendix A

20

GO-4

JUL 12

GO-4, Assisted Living Facility Provider Enrollment, Statement of Intent to Accept Room and Board Supplementation

ACS, GO-4, provider enrollment, assisted living, AL, Room and Board supplementation, R&B, aging and community services

2011-11-04

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