New Jersey Department of Human Services

Division of Aging Services

SERVICE COST RECORD

1.	Name of Participant (First and Last)

2.	Medicaid Number

3.

Authorized

Medicaid Waiver or Medicaid State Plan Service	4.

Cost

Per Unit	5. Month/Year:

5. Month/Year:

5. Month/Year:

6. Unit(s)	7.

Monthly Cost	6. Unit(s)	7.

Monthly Cost	6. Unit(s)	7.

Monthly Cost
8.	Total Estimated Monthly Service Costs
$
$
$
9.	Total Monthly Service Costs
$
$
$
10.	Difference (Line 8 Minus Line 9)
$
$
$
11.	Reconciled/Verified Service Costs
$
$
$
12.	Signature of Care Manager

13.	Date

WPA-4

JUL 12

WPA-4, Service Cost Record

WPA-4, WPA, Service cost record, waiver, monthly cost, unit cost, service, DOAS, aging services

2007-10-24

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human services