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Form # Title PDF/WORD Instruction/ Comments
ACS-11 Primary Health Care Provider Report on Medicaid Beneficiary pdf 
doc 
 
ACS-13 Client Tracking Form pdf 
doc 
Instructions
pdf 14k 
doc 31k 
ACS-16  Take Control of Your Health Workshop Information Cover Sheet pdf 
doc 
 
ACS-17 Take Control of Your Health Notification of Upcoming Workshop pdf 
doc 
 
ACS-18 Take Control of Your Health Attendance Log pdf 
doc 
 
ACS-19 Take Control of Your Health Participant Information Survey pdf 
doc 
 
ACS-19A Take Control of Your Health Participant Information Survey (Spanish) pdf 
doc 
 
ACS-20 Take Control of Your Health Workshop Evaluation pdf 
doc 
 
ACS-20A Take Control of Your Health Workshop Evaluation (Spanish) pdf 
doc 
 
ACS-21 Take Control of Your Health Participant Certificate of Completion Template pdf 
doc 
 
ACS-21A Take Control of Your Health Participant Certificate of Completion (Spanish) pdf 
doc 
 
ACS-22 Take Control of Your Health Peer Leader Agreement pdf 
doc 
 
ACS-23 Take Control of Your Health Peer Leader Contact Info and Training Verification pdf 
doc 
 
ACS-24 Take Control of Your Health Notification of Upcoming Peer Leader Training pdf 
doc 
 
ACS-27 Take Control of Your Health Peer Leader Training Certificate of Completion pdf 
doc 
 
ACS-28 Take Control of Your Health Master Trainer Checklist for Observing Peer Leaders pdf 
doc 
 
ACS-29 Take Control of Your Health Group Leader Script (English) pdf 
doc 
 
ACS-29A Take Control of Your Health Group Leader Script (Spanish) pdf 
doc 
 
ACS-32 Take Control of Your Health Tommando Master Trainer's Checklist for Observing Peer Leaders pdf 
doc 
 
ACS-33 Take Control of Your Health Non-Disclosure Agreement pdf 
doc 
 
ACS-34 Participant Record Transfer Cover Sheet pdf
doc 
 
AL-6 Assisted Living/Adult Family Care (AL/AFC) Referral for the Managed Long Term Services and Supports (MLTSS) Medicaid Waiver pdf 
doc 
Instructions for Completing the Assisted Living/Adult Family Care Referral (AL-6) Form
pdf 13k 
doc 25k 
CP-2 Long Term Care Referral pdf 
doc 
Instructions
pdf 14k 
doc 30k  
CP-3 PACE Request for Deeming of Continued Eligibility for Nursing Facility Level of Care pdf 
doc 
 
CP-4 PACE Request for Waiver of the Annual Recertification Assessment for Nursing Facility Level of Care pdf 
doc 
 
CP-7 Non-MFP Nursing Facility Transition to the Community

pdf

doc

 
CP-10 Special Request pdf 
doc 
Instructions for Completing the Special Request (CP-10) Form
pdf 24k 
doc 26k 
CP-11 PACE Enrollment Notification pdf 
doc 
 
CP-18 Participant Withdrawal pdf 
doc 
 
CP-23 Notice of Program Disenrollment pdf 
doc 
 
CSS-6 Client Demographic Data pdf 
doc 
 
CSS-7 Financial Profile pdf 
doc 
 
CSS-8 Client Funding Utilization pdf 
doc 
 
CSS-9 Discharge Information (formerlyWFS-4) pdf 
doc 
 
CSS-10 Waiting List Application (formerlyWFS-5) pdf 
doc 
 
CSS-11 Day Health Services Monthly Attendance Roster pdf 
doc 
 
CSS-12 Application for Letter of Agreement for Health Services pdf 
doc 
 
HA-1 Eligibility Application, Hearing Aid Assistance for the Aged and Disabled (HAAAD) pdf 
doc 
 
JACC-1 JACC Provider Application, Sections I & II: Instructions, General Information, Ownership Disclosure Form, Debarment & Suspension Certification, and NJ W-9 / Vendor Questionnaire

pdf 
doc 

pdf 
doc 

JACC-2 JACC Provider Application, Section III: Adult Day Health Services

pdf 
docx 

 
JACC-3 JACC Provider Application, Section III: Attendant Care Evaluation

pdf 
docx 

 
JACC-4 JACC Provider Application, Section III: Chore Services

pdf 
docx 

 
JACC-5 JACC Provider Application, Section III: Environmental Accessibility Adaption

pdf 
docx 

 
JACC-6 JACC Provider Application, Section III: Facility-Based Respite Care Services

pdf 
docx 

 
JACC-7 JACC Provider Application, Section III: Home Delivered Meal Services

pdf 
docx 

 
JACC-8 JACC Provider Application, Section III: Homemaker Services

pdf 
docx 

 
JACC-9 JACC Provider Application, Section III: In-Home Respite Care Services

pdf 
docx 

 
JACC-10 JACC Provider Application, Section III: Personal Emergency Response System (PERS)

pdf 
docx 

 
JACC-11 JACC Provider Application, Section III: Social Adult Day Care

pdf 
docx 

 
JACC-12 JACC Provider Application, Section III: Specialized Medical Equipment & Supplies (SME)

pdf 
docx

 
JACC-13 JACC Provider Application, Section III: Transportation Services

pdf 
docx 

 
JACC-404 2016 JACC Co-Pay Worksheet pdf 
doc 
 
LTC-2 Notification form Long-Term Care Facility of Admission or Termination of a Medicaid Beneficiary pdf 
doc 
Instructions
pdf 20k 
doc 32k 
LTC-4 Hospital Preadmission Screening Referral pdf 
doc 
 
LTC-19 Request for Billing Assistance pdf 
doc 
 
LTC-26 Pre-Admission Screening and Resident Review (PASRR) Level I Screening Tool pdf 
doc 
Instructions
pdf 
doc 

PowerPoint
pdf 
LTC-29 Notice of Referral for Level II Pre-Admission Screening and Resident Review (PASRR) Evaluation pdf 
doc 
 
LTC-34 EARC-PAS Enhanced At-Risk Criteria Screening Tool pdf 
doc 
Instructions for Completing the LTC-34, Enhanced At-Risk Criteria Screening Tool
pdf 16k 
doc 28k 
LTC-36 DHS/DoAS Notice of Privacy Practices -- English pdf 
doc 
 
LTC-36A DHS/DoAS Notice of Privacy Practices -- Spanish pdf 
doc 
 
LTC-37 Assisted Living Facility - Provider Enrollment Statement of Intent o Accept Room and Board (R&B) Supplementation

pdf

doc

 
LTC-38 Assisted Living Facility Notification of Room and Board (R&B) Supplementation

pdf

doc

 
LTC-39 Room Supplementation Record

pdf

doc

 
LTC-D1 At Risk Criteria for Nursing Home Placement pdf 
doc 
 
MFP-75 Enrollment Request & Instructions pdf
doc 
 
MFP-76 MFP Days/Readmission Reasons Statistical Report pdf
doc 
 
MFP-77 Eligibility Screening Tool pdf
doc 
 
NF-1 Nursing Facility Quarterly Financial Data xlsx   
NF-1A Nursing Facility Quarterly Financial Data Form FAQs pdf 
doc 
 
OPG-5 Physician Questionnaire for Goals of Treatment pdf 
doc 
 
PA-4 Physician Certification pdf 
doc 
Instructions
pdf 8k 
doc 23k 
UA-1 Universal Application for PAAD, Senior Gold and Other Special Benefit Programs (for individuals applying for PAAD or Senior Gold benefits for the first time) pdf 
doc 

Instructions
pdf 
doc

Video Tutorial  

WPA-1 Long Term Care Re-Evaluation pdf 
doc 
Instructions for Completing the Long Term Care Re-Evaluation (WPA-1) Form
pdf 24k 
doc 34k 
WPA-2 Plan of Care pdf 
doc 
Instructions
pdf 41k 
doc 74k 
WPA-3 Monitoring Record pdf 
doc 
 
WPA-8 Individual Service Agreement pdf
doc 
 

 

 
 
 
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