New Jersey Department of Human Services

Individual Service Agreement

1.	Service	Start:	Revise:	Stop:
Effective Date
Effective Date
Effective Date
2.	Participant:	3.	ID Number:
4.	Address:	5.	Telephone No.:
6.	Date of Birth:
7.	Program:	JACC	Other (specify):
8.	Care Manager No.:
The following service has been authorized for the above client according to the schedule and cost shown.
Service
9.	Service name
10.	Code
Initial	Revise
11.	Unit of Service
12.	Units per Visit
13.	Frequency of Service
14.	Total Units per Week
15.	Authorized Cost per Unit
16.	Authorized Cost per Week
17.	Authorized Cost per Month (weekly cost X 4.33)
Provider:

(DHS will pay only for those services authorized and provided pursuant to program rules.

(This notice confirms arrangements for services made by the Care Manager. You must submit an invoice at the conclusion of service or end of each month of service.

(If there is a change in the participant's condition, contact the Care Manager immediately.

(Contact the Care Manager if you note errors in the above information or if you have any questions.	18.	Specifications:

19.	Stop Services - Reason:

20.	Resume Services - Date:

21.	Other - Specify:

22. Provider Name

23. Provider EIN No.

24. Provider Signature and Title (Optional for Traditional and Non-Traditional Providers)

Date

25. Care Manager’s Name and Title

Date

Flow:	1.	Authorizing Care Manager completes, signs, and sends to Service Provider.

2.	Care Coordinator forwards to DoAS Billing Agent.

WPA-8	3.	ADHS Provider is required to sign on Line 24 and returns to Care Manager.

OCT 14	4.	ADHS Provider sends copy of this form with PA request to ADHS Central Office.

WPA-8, Individual Service Agreement

WPA-8, individual service agreement, aging services, DOAS, JCN-421,

ewhite

2016-03-24

Windows User

NJDHS