N.J. Admin. Code § Tit. 8, ch. 133, app L
Current through Register Vol. 56, No. 21, November 4, 2024
| APPENDIX L | |
| BUSINESS MANAGER'S STATEMENT TO SSI APPLICANT | |
| _____________________________________ | ______________________________________ |
| (Client's Name) | (Date) |
| _____________________________________ | ______________________________________ |
| (Hospital) | |
| _____________________________________ | |
| _____________________________________ | |
| (Client's Address) | |
| The Social Security Administration has informed us that: | |
| ____ | Your SSI application was denied. |
| ____ | They issued a retroactive SSI check to you or your payee. |
| The following is a computation of the amount due for your Interim Assistance placement: | |
| 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-9A (9/14/00) | |
N.J. Admin. Code Tit. 8, ch. 133, app L