N.J. Admin. Code § Tit. 8, ch. 133, app C
Current through Register Vol. 56, No. 24, December 18, 2024
| APPENDIX C | |
| NEW JERSEY DEPARTMENT OF HUMAN SERVICES | |
| Division of Mental Health Services | |
| CONTRACT FOR INTERIM ASSISTANCE | |
| THIS AGREEMENT is made on this ____ day of __________ in the year ______. | |
| WITNESSETH, that I, ______________________________________ the undersigned, | |
| for and in consideration of payments to be made to me as provided herein, do | |
| hereby covenant and agree as follows: | |
| 1. I AGREE to accept into my home ___________ from the __________________ and | |
| (Hospital Name) | |
| agree to furnish said individual with food, lodging, and other usual and | |
| necessary incidentals for the proper maintenance of the said individual | |
| and his or her well being. | |
| 2. I AGREE to accept the sum of $ ____________ per day ($ ____________ per | |
| month) from the _________________________ at ________________________ as | |
| (Hospital) | (Location) |
| compensation for maintenance that I shall furnish the said individual. I further understand that the above agreed upon daily compensation rate is established at rates determined by the Social Security Administration in conjunction with the Commissioner of the Department of Human Services and is payable the beginning of the month of services. Individuals with other income shall make payments directly to the housing provider. If advance payment is received and the individual has also paid or the individual leaves the facility prior to the first of the month for which payment was made, that IA payment must be returned to the hospital. If the individual leaves a congregate living situation any time during the month, the congregate home operator agrees, at the discretion of the hospital, to: | |
| (1) hold the bed open for the individual's return; (2) accept another individual referred from the hospital in their place; or, where one or two cannot be agreed upon, (3) refund hospital-advanced funds for the unoccupied days, if requested by the hospital. | |
| 3. I AGREE to immediately contact the _______________________________________ | |
| (Designated Emergency Screening Service) | |
| by telephone in the event of need for emergency psychiatric care, and | |
| _______________ by telephone in the event of need for emergency medical | |
| Hospital | |
| care, notifying them of the full details of the said individual's | |
| condition and to abide by such directions as shall be given. In the event | |
| of serious emergency psychiatric care, I will contact the | |
| ________________________________________ immediately by telephone after | |
| (Designated Emergency Screening Service) | |
| care has been given notifying them of the full details. In the event of | |
| serious emergency medical care, I will contact the ______________________ | |
| Hospital | |
| immediately by telephone after care has been given notifying them of the | |
| full details. | |
| 4. I AGREE to give the ______________________ at ___________________________ | |
| (Hospital) | (Location) |
| thirty (30) calendar days notice in writing of my intention to terminate this contract; otherwise it shall continue in full force and effect as long as the said individual is under my care, or is subject to termination notice if standards are not maintained. | |
| 5. An Interim Assistance Payee is not entitled to receive dual payments for care provided. A home operator, family member, or other payee (as applicable) must therefore: (1) notify the hospital upon learning that a resident received his or her first SSI or other payment and also provide the effective date of such payment; (2) refund the hospital the amount of Interim Assistance payments received after the first SSI or other payment is received if such payment represents duplicate compensation; (3) refund the hospital the amount of Interim Assistance funds from the retroactive SSI payment, which represents a duplicate payment for the time period from SSI application to receipt of funds; and (4) notify the hospital immediately should the client terminate residency at the home. | |
| IN WITNESS WHEREOF, I hereunto set my hand the year and day first written | |
| above. | |
| _____________________________________ | |
| (Signature of Home Operator and/or | |
| Responsible Family Member) | |
| Signed and delivered in the presence of | |
| _______________________________________ | |
| Witness | |
N.J. Admin. Code Tit. 8, ch. 133, app C