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

Notification of Room and Board (R&B) Supplementation

Submit within 15 days of effective date to:

New Jersey Department of Human Services

Division of Aging Services

P.O. Box 807

Trenton, NJ 08625-0807	Or FAX to the Quality Assurance Unit (QAU) at:

(609) 588-7683

Name of Assisted Living (AL) Facility

Telephone Number

Name of AL Resident/GO Participant

Medicaid Number

Admission Date

Effective Date of R&B Supplementation

agreement if after admission:	Is a Medicaid unit available at this time?

Yes No
Unit to which upgraded:

Monthly cost of upgrade:

Consequence of Non-Payment:

Name of Voluntary Third-Party Payer

Relationship

Address

Signature	Date

Name of AL Facility Representative

Title

Signature	Date

Once submitted, a representative from the Division will contact you within two weeks if there are questions regarding this notification. Otherwise, the Notification of R&B Supplementation is acceptable.

c:	GO Care Manager

GO Participant File

Appendix B

20

GO-5

NOV 13

GO-5, Notification of Room and Board Supplementation

GO-5, notification of room and board supplementation, assisted living facility, R&B, AL, quality assurance unit,

Dennis McGowan

2011-11-04

Windows User

human services