New Jersey Department of Human Services

Division of Aging Services

PARTICIPANT RECORD TRANSFER COVER SHEET

Name of Participant:	Date of Birth:
Program:	Jersey Assistance for Community Caregiving (JACC)

Other	Date of Transfer:
Medicaid/JACC Number:	Social Security Number:
Residential Setting: Private Residence Class B Boarding Home
Address Change? Yes No
Old Address:	New/Current Address:
Old County:	New/Current County:
Participant Phone Number:
Emergency Contact Person/Phone:
The participant identified above has been transferred to your agency for care management (CM).
Receiving Care Management Agency contact information:
Agency:	Phone:
Address:
Enclosed care copies of information from the original Referral Packet:

PA-4 CP-2/SINQ CP-5 NJ Choice

Release of Information Choice of Care Agreement of Understanding

Enclosed are also copies of the most recent documents:

Monitoring Record (for month of enrollment and for past 12 months/I year

Assisted Living/Adult Family Care Cost Share, if applicable

LOC Reevaluation (WPA-1) NBCAT

Plan of Care (WPA-2) HCBS Database update:

Service Cost Record (including ISAs and new CM Agency)

PEP Approval Documentation High Risk: No Yes Critical*

MCO: *If Critical, date of CM phone conference:

Other:
Date:
Date:	Next Due Date:
Change of Address Notification Made:	N/A	Monthly Contact completed on:
County Welfare Agency
Quarterly Visit completed on:
Office of Community Choice Options

Northern Southern
Plan of Care completed on:
Social Security Administration
LOC Reevaluation completed on:
Sending Care Management Agency contact information:
Care Manager Name:	Agency:
Address:	County:
Phone:	Email Address:

Sending Care Manager Signature	Date
Sending CM Supervisor Signature	Date

CP-10 (GO 491)

JUL 12	-2-

ACS-34

FEB 15

CP-10, Special Request

CP-10, GO 491, Special Request, JACC, CAP, ACS, Aging

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2015-02-26

human services