Facility Name:	Facility Address:	Date:

Resident’s Name	Residents’ Medicaid No.	Amount Paid in Room Supplementation	Name of Responsible Third Party Payer	Third Party Payer Phone Number

When complete, fax to Jean King at 609-588-7683.

New Jersey Department of Human Services

Division of Aging Services

ROOM SUPPLEMENTATION RECORD

LTC-39

NOV 15

OC-48A, Attendance Sheet

attendance, sign in, oc-48, oc-48a

dmcgowan

2015-11-12

Windows User

NJDOH