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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-15 Hospital PAS Pilot Screen for Community Services pdf 
doc 
 
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-25 Take Control of Your Health Peer Leader Training Evaluation pdf 
doc 
 
ACS-26 Take Control of Your Health Peer Leader Feedback Form 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 Welcome and Confidentiality Statement (English) pdf 
doc 
 
ACS-29A Take Control of Your Health Welcome and Confidentiality Statement (Spanish) pdf 
doc 
 
ACS-30 Waiver Services Summary and Health Plan Coordination pdf 
doc 
 
ACS-31 Acknowledgement of Receipt of Notice of Privacy Practices pdf 
doc 
Notice of Privacy Practices
pdf 443k 
ACS-34 Participant Record Transfer Cover Sheet pdf
doc 
 
AL-2 Assisted Living Care Plan Approval pdf 
doc 
 
AL-3 Cost Share Worksheet pdf 
doc 
Instructions for Completing the AL-3 Cost Share Worksheet
pdf 58k 
doc 74k 
AL-6 Assisted Living/Adult Family Care (AL/AFC) Referral for the Global Options for Long Term Care (GO) Medicaid Waiver pdf 
doc 
Instructions for Completing the Assisted Living/Adult Family Care Referral (AL-6) Form
pdf 13k 
doc 25k 
AP-2 Universal Application for PAAD, Senior Gold and Other Special Benefit Programs (for individuals applying for PAAD or Senior Gold benefits for the first time) Application  Instructions 
AP-2A Medicare Part D PDP Formulary Enrollment Assistance Form 
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-5 Notice of Program Enrollment pdf 
doc 
 
CP-6 Choice of Care 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 
 
CP-28 Agreement of Understanding pdf 
doc 
 
CP-28A Agreement of Understanding (Spanish) 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 
 
GO-1 (GO499) Participant Handbook pdf 
doc 
 
GO-2 (GO499) Participant Handbook Cover Sheet pdf 
doc 
 
GO-3 (GO422) Participant Enrollment Agreement w/Signature Page pdf 
doc 
 
GO-4 Assisted Living Facility - Provider Enrollment Statement of Intent to Accept Room and Board (R&B) Supplementation pdf 
doc 
GO-5 Assisted Living Facility Notification of Room and Board (R&B) Supplementation pdf 
doc 
 
HA-1 Eligibility Application, Hearing Aid Assistance for the Aged and Disabled (HAAAD) pdf 
doc 
 
JACC-404 2014 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-21 Notice of Ineligibility (PACE) pdf 
doc 
 
LTC-24 Needs-Based Care Allocation Tool (NBCAT) Quarterly Data Report pdf 
doc 
 
LTC-26 Pre-Admission Screening and Resident Review (PASRR) Level I Screening Tool pdf 
doc 
LTC-29 Notice of Referral for Level II Pre-Admission Screening and Resident Review (PASRR) Evaluation pdf 
doc 
 
LTC-31 Transition Plan pdf 
doc 
 
LTC-32 Need-Based Care Allocation Tool pdf 
doc 
User Guide
pdf 22k 
doc 38k 
LTC-33 Options Counseling Attestation Statement 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-D1 At Risk Criteria for Nursing Home Placement pdf 
doc 
 
LTC-L6 Revised and Changed to LTC-29  
 
LTC-L11 NJ LOC PASRR Letter, Non-Medicaid Groups pdf 
doc 
 
MFP-75 Enrollment Request pdf
doc 
 
MFP-76 MFP Days/Readmission Reasons Statistical Report pdf
doc 
 
MFP-77 Eligibility Screening Tool pdf
doc 
 
OPG-5 Physician Questionnaire for Goals of Treatment pdf 
doc 
 
PA-4 Physician Certification pdf 
doc 
Instructions
pdf 8k 
doc 23k 
PR-2 Assisted Living Facility Patient Pay Liability Worksheet pdf 
doc 
Instructions
pdf 8k 
doc 23k 
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-4 Service Cost Record pdf 
doc 
Instructions for Completing the Service Cost Record (WPA-4) Form
pdf 22k 
doc 23k 
WPA-9 JACC Co-Pay Worksheet pdf 
doc 

 
 
 
 
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