N.J. Admin. Code § Tit. 8, ch. 133, app H
BUSINESS MANAGER'S STATEMENT TO INTERIM ASSISTANCE RECIPIENT
| ...................................... | ...................................... |
| (Client's Name) | (Date) |
| ...................................... | ...................................... |
| (Hospital) | |
| ...................................... | |
| ...................................... | |
| (Client's Address) |
The Social Security Administration has sent us a check representing your retroactive and initial benefits from the SSI Program.
According to the authorization you gave us on form MH-30, we have applied to that check an amount equal to the amount of recoverable assistance we gave you while your application for SSI was being processed or your SSI payment was suspended or terminated, as follows:
| 1. Amount of Interim Assistance provided | $ .......................... |
| 2. Amount of SSI check | $ .......................... |
| 3. Patient Trust Fund balance | $ .......................... |
| 4. Total available resources (2 + 3) | $ .......................... |
| 5. Amount of assistance hospital can recover | $ .......................... |
| 6. Amount of assistance given to you by | $ .......................... |
| county/local welfare agencies | |
| 7. Amount of assistance recovered from PTF | $ .......................... |
| balance | |
| 8. Net amount due you (4-5-6-7) (check enclosed) | $ .......................... |
| 9. Net amount due State Treasurer (1-5-7) (bill | $ .......................... |
| enclosed) |
If you disagree with this computation, you have the right to come to this office to discuss the matter. If after such discussion you are not satisfied, you may contact the State Division of Mental Health Services to request an administrative review. You should make the request through the Department of Human Services, Division of Mental Health Services, PO Box 727, Trenton, New Jersey 08625-0727.
| ..................................................... | |
| (Hospital) | |
| ..................................................... | |
| (Name, Title) | |
| Distribution: | |
| Client-Original | Social Services Director |
| Business Manager | Placement/Financial Coordinator |
| Division Fiscal Officer | |
| Form FS-9 (Revised | |
| 9/14/00) |
N.J. Admin. Code Tit. 8, ch. 133, app H