New Jersey Department of Human Services (DHS)

Division of Aging Services (DoAS)

PACE Administration

PO Box 807

Trenton, NJ 08625-0807

PACE Request for Waiver of Nursing Facility Level of Care Recertification

To request a Waiver of Nursing Facility Level of Care Recertification, complete the information below and submit all required documentation listed on the form to DoAS, at least 45 days prior to the last annual recertification authorization date.

From (Name/Title):
PACE Organization:
Email Address:
Telephone Number:	Fax Number:
Date of Request:	Recertification Due Date:
Participant Name:	Date of Last Assessment:
DoAS will only initiate the review of this request when all of the following documentation has been received. Omitting any information requested below will delay approval of the waiver request.

Justification summary from IDT

Diagnosis of chronic or disabling condition

Last comprehensive assessment by all relevant disciplines

Last 2 IDT care plans

Initial LOC assessment and updated LOC assessment

History and Physical

Physician and nursing progress notes

All specialty consultant notes (any discipline)

Social work notes

Diagnostic tests supporting request

Medication and treatment record

Other relevant documentation supporting the request

Above request is:
Authorized/Date:	Not Authorized/Date:
Name and Title of Reviewer:
Signature:
Date:	Telephone:

CP-4

MAR 18

CP-4, PACE Request for Waiver of Annual Recertification Assessment

CP-4, PACE, Waiver, Annual Recertification, Nursing Facility, level of care

Windows User

2018-03-13

human services