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Individuals seeking financial assistance from Medicaid for long-term care services must meet the program’s medical (clinical) and financial eligibility requirements.  The steps necessary to attain Medicaid approval are known as the Pre-Admission Screening (PAS) process.

The PAS process is administered statewide by Long Term Care Field Office (LTCFO)counselors.  Referrals are received in the LTCFO from a variety of sources, including:

  • Hospitals, including rehabilitation, psychiatric, and acute care;
  • Nursing Facilities and Special Care Nursing Facilities;
  • Assisted Living Residences, Comprehensive Personal Care Homes and agencies offering Adult Family Care and Assisted Living Programs; and
  • The community, for individuals in need of long-term care services or their caregivers, through community agencies including County Welfare Agencies and the County Offices on Aging/Area Agencies on Aging.

Agencies making referrals for PAS are required to submit the following forms to the LTCFO:

  • Hospitals use Form LTC-34 (Word, PDF) or Form LTC-4 (Word, PDF), the Hospital Pre-Admission Screening Referral. 
  • Nursing homes use Form LTC-2 (Word, PDF), the Notification from Long Term Care Facility of Admission or Termination of a Medicaid Client.
  • County Welfare Agencies use Form CP-2 (formerly Form JCN-417) (Word, PDF).
  • Physicians referring adults in the community through County Welfare Agencies use Form PA-4 (Word, PDF), the Certification of Need for Patient Care in a Facility other than Public or Private General Hospital. Physicians referring children in the community shall contact the Division of Disability Services for screening and physician Certification for Children form.
  • Assisted Living waiver providers use Form AL-6 (Word, PDF), the Assisted Living/Adult Family Care (AF/AFC) Referral Form.
  • Individuals residing out-of-state who are seeking long-term care services in New Jersey use the Out-of-State referral packet available through the LTCFOs. Please contact the LTCFO for a referral packet.

Note:  Approval for Medicaid Long Term Care Services is a two-fold process.  Waiver eligibility is contingent upon the financial eligibility determination for Medicaid by the County Welfare Agency or Board of Social Services.

Below is a table with the referral source, required referral documents and the critical information that needs to be completed to initiate the PAS.


Referral Source

Documents Required

Critical Information

All Hospitals




LTC-4 or LTC-34





Name of hospital, client’s name, date of birth, Social Security number (SSN), eligibility status, name of the social worker or discharge planner.


Nursing Facility


Client’s name, SSN, provider’s name, date of admission, client’s previous location and status:

  • Private to Medicaid
  • PAS Exempt

AL Waiver Providers


Client’s name and contact information, SSN, diagnosis, name of facility.


County Welfare Agency 








PA-4 (or its equivalent).

Client’s name, SSN, Medicaid number if available, address including county, telephone number, income if client wants a waiver, intake worker.

Client’s name, date of birth, current living situation, diagnosis, ADL needs, #10 must be “yes,” MD signature, date.

Adult Protective Services (APS)

PA-4 (or its equivalent)

Client’s name, date of birth, current living situation, diagnosis, ADL needs, #10 must be “yes,” MD signature, date.

Out-of-State Referral

Out-of-State packet

Client's name, address, SSN, contact person with phone number.

Physician Referrals

PA-4 (Adults)

Physician Certification for Children (Pediatric age birth through 20)

Client's name, SSN, diagnosis.


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