New Jersey Department of Human Services

NURSING FACILITY TRANSITION TO THE COMMUNITY (NON-MFP)

Date Faxed

Name of Person/ Title Completing Form

To: Alisa Mead

Assistant MFP Director

(609) 588-7267 (Phone)

(609) 588-3330 (FAX)

Phone Number

Participant Name

Social Security Number

Date of Birth

Age

SSI Recipient

Yes No
Medicaid Number

Effective Date

Medicare Number

Met MLTSS eligibility and did not transition due to meeting the Cost Effectiveness Threshold.

Discharge Services:

State Plan Services Private Pay

MLTSS Medicare Services

Case Conference Initiated

Cost Effective IDT requested

Date: ____/____/_________

Discharge Facility Name

Facility Type

NF: _________________________

SCNF:

Type: _________________________
Discharge Facility Address

Date of Admission to NF/SCNF

IDT Done

Yes No	Date

Date of Discharge from NF/SCNF

Discharge To

Private Home/Apartment ALR/CPCH AFC RHCF
Phone

Address

Name of Care Manager

Phone

Email of Care Manager

What constitutes a transition?

To be considered a discharge or transition from a NF to the community and reported to OCCO, contact must be made at the facility through a NJ Choice Assessment, follow-up, Options Counseling, and/or a Section Q referral. Options Counseling and any assistance given to the client needs to be documented in the IPOC section of the NJ Choice Assessment and your monitoring notes. NOTE: IF TRANSITION IS A MFP, USE MFP 75

CP-7

MAY 14

CP-7, NF Transition to the Community (non-MFP)

CP-7, community programs, nursing facility, transition to community, non-MFP, MFP,

Windows User

2014-11-03

human services