NEW JERSEY FIREMEN'S HOME (A Smoke,fwee facniiiy! 565 Lathrop Avenue, Boonton, NJ 07005 trrc __ RC __ 973~334~0024

A!P!P!LUCCA TUOINJ !FOR AllJMUSSUON llfPlOlfi'il compie~n~:m of application, please contac~ yourr ~respective County Marrilagen-.

!DO NOT SEND APPLICATION DIIRECll V 10 lHE F~IREMEN'§ HOME.

Date: ______ _ TO THE BOARD OF MANAGERS Application is hereby respectfully made for admittance to the New Jersey Firemen's Home.

NAME OIF AIPIPUCAN1r:

t GENERAliNIFORMAT~ON CONCERNING PROSPECT~VIE AIPPUCANT

Home Address

City------ - -------State _______ Zip ____ _

Telephone Number(s) ______________________ _

Social Security Number--- --- --- - ------ Age---~-Date of Birth _____ Birthplace. ________ Citizen of ____ --,-_

Applicant's marital status Does applicant have children?_ Yes No

Applicant is now at ___ Home _ Hospital* _ Nursing Home;, Othe('

Please identify location. *Name ______ . ___________ _

Contact Person @ Facility: ___________ _

Address _ ________________ _

Tele # __________ How Long? ____ _

Have you ever made a previous application for admittance to the New Jersey Firemen's

Home? Yes No

If yes, when ___ ·---------state reason for wishing to enter now

Applicant's primary language_ English _Other, please specify _______ _

Education __

Religion*..:...__ _ _

Former Occupation __________ _

·------ Church.-.:*-=---------------Pastor Tele # --------- - - ---- ------------

A. Please identify person(s) to be notified in case of emergency:

1. Name Address ___________ _

City-----------State _________ Zip ___ _

Tele # Home (_) Business (_) Cell (__ ) ____ _

Email: _______________ _ FAX: -----------Occupation Relationship _ _______ _

Wi ll this person(s) help defray cost of Health Care/Nursing Horne Care? _ Yes _No

* Optional Month Year

Application for Admission Revised: 07 2012

SAMPLE

2. Name Address -------------------------- -------------------------City----------· State -----·----------- Zip ___ _ Tele # Horne (_) ____ Business (_) ______ _ Cell (_) ____ ___

Email: ____ . FAX: --~-----------------

Occupation Relationship ----~----------­

Will this person(s) help defray cost of Health Care/Nursing Home Care? _ Yes _ No

3. Name --- _______________ Address ___________ __

City __ _ State Zip -------- ------------------ -------Tele # Home (_ ) ___ , Business (_) Cell (_ ) ____ ___

Email: FAX: ------------------Occupation --------------- Relationship ----------------~

Will this person(s) help defray cost of Health Care/Nursing Home Care? _ Yes _ No

Who holds Power of Attorney,., , if any: *PLEASE ATTACH COPY

Name ___ . __________ Tele # (_) ________ _

Living Will"/ Advance Directive*: _ Yes No *PLEASE P,TTACH COPY

Funeral I Burial Arrangements: 1. Name of Funeral Home -----------------------------------

Address

Tele # (_ )_ ________ Prepaid Yes No

2. Cemetery Plot:

Name of cemetery _______ , ____________________________ __

Address _____________________________________ ___

Tele#(_ )

3. Donation of Body Parts: Yes

Prepaid _ Yes _ No

No

If yes, what and to whom? _____________________________________ _

Cremation: _ Yes No

Military Status: _ Yes _No If yes, Branch of Service ________________________ _

Dates of Service: Service Serial Number: --------

Type of Discharge: __________________________________________ _

II . MEDICAL INFORMATION CONCERNING APPliCANT

A. Current problems, if any ________________________________ _

How long has this problem existed? _________________________________ _

Please list current medications

Applicant's last hospitalization ______________________________ _

For what?

How long?--------------------------------------

2

Application for Admission Month Year

Revised: 07 2012

SAMPLE

Has the applicant ever been in a Nursing Home? Yes _ No

Where How long? _ _ _ ____ _

Why did resident leave Nursing Home?----------------­

Any problems there? -----·

B. Applicant's spe9ial needs:

Grooms self _Yes _ No

Dresses self Yes No

Bathes self Yes No

Special diet _Yes _No

Please specify _ ________ _

Special skin care _Yes No Other _____ _______________________ _

Please list applicant's current clothing sizes: waist

Applicant's physical mobility Walks unassisted

_Walks only with assistance Uses walker

Is applicant incontinent? _Yes _No

Does applicant wear glasses? Yes No

inseam_ shirt shoe

_ Uses wheelchair

Bed-bound

Bowel _ Bladder _ Both

When was last eye exam?----------------------­

Does applicant wear dentures? Yes No

When was last dental/gum exam?------------------­

Oxygen needed _ Catheter

Does applicant have any physical deformities that require special care and attention?

_Yes _._No If yes, please describe-----------------

C. Applicant's mental status

Does the applicant usually desire to be dressed and groomed properly? _Yes _No

If no, please explain------------------ -----­

Does the appl icant manifest any signs of unusual or bizarre behavior? _Yes No

_Occasionally Is the applicant alert? _Yes _No Cooperative? _Yes _No

Is the applicant quiet and controlled?

Is the applicant combative? _Yes

Yes No

No

Does the applicant have episodes of crying, screaming, yelling?

Does the applicanr have a tendency to wander? _Yes _No

Yes _No

Does the applicant have violent outbursts of temper? _Yes _No

Does the applicant generally get along well with others? _Yes _No

Does the applicant like to converse and socialize with others? _ Yes _ No

Does the applicant enjoy/appreciate the opportunity for external activities? _Yes _ No

Does the applicant tend to be depressed and withdrawn? _Yes _No

State any other sign ificant event or occurrence you recall about the applicant's mental

condition __________ .

3

Month Year Application for Admission Revised· 07 2012

SAMPLE

PRIMARY INSURANCE COMPANY _______________ _

Policy# ____ ______ _ Group # ________ _

Policy H.older --------- DOB _____ _

Relationship To Patient ______ .

SECONDARY INSURANCE COMPANY __________ . _ ____ _

Policy# _______ ___ _ Group # ______ _

Policy Holder DOB _____ _

Relationship To Patient ____________ ___ _

PRESCRIPTION INSURANCE COMPANY----- ---------

Policy# _ _ _ _____ . Group # ________ _

Policy Holder _________ _ DOB _____ _

Relationship To Patient. ____________________ _

PILEASE ATTACH COPIES, !BOTH F!FUJNT AND /BA CK, OF AILIL UNSURANCE CARDS WITH AIPPLUCA TION.

Will the applicant pay for stay with his/her own funds? _Yes _No

Has the applicant applied, or will the patient be applying for Medicaid or Public Assistance?

Yes _No If applicant has applied:

Date Caseworker's Name ------ ------------Where Tele # --------------

Does applicant have any other insurance that will cover Nursing Home?

_Yes No If yes, please identify:

Company ___ ·- ----------------------Policy Number _______ Agent's Name _________ _

o fLEASE DO NOT REFILUORDER /PRESCRIPTIONS PRIOR TO ADMISSION. ON ADMISSION, OVR MEDICAL DIRECTOR WILL ASSESS ALL MEDICA TJONS CURRENTLY IN USE BY THE APPLICANT.

0 AS PART OF TIJ-IE ADMISSION AGREEMENT, THIS FAC§UTV DOES NOT PERMIT PHARMACEUTICA!LS FROM OUTSffDE PHARMACIES. THIS IS IN THE BEST INTEREST OF SAFETY AND ECONOMIC CONSIDERATIONS FOR EACH RESIDENT. FOR /FURTHER QUESTIONS, PLEASE CONTACT OUR SOCCffA!L WORKER OR DIRECTOR OF NURSING.

4 Month Year

Application for Admission Revised: 07 2012

SAMPLE

~V. IF~NANC~Al ~NFORMAT~ON CONCERNiNG APPUCANT

A. Caslh A§§e~s

Bank Location ----- -----------------------------Checking Acct. No. Savings Acct. No. ________ _

Balance in Account $ Balancg in Aceount $ ____________ _

Certificates of Deposit? _ Yes No If yes, approx. amt. $ ------------Safe Deposit Box? _ Yes _No

If yes, please indicate bank and location ____________ ____________________ _

R i\llo1!11~hiy ~Ji1come

Social Security $ Railroad $_ Interest $ ____ _

Private Pension $ Civil Service $ -------- ------ Dividends$ _________ _

Veterans Benefits $ Other $ -----------c. Rea! IEs~a~e Assets

Does applicant own home? _Yes No Approx. Value$ __________ _

Does applicant own any other property? Yes No

If yes, where is property located?

Does applicant receive any "rental" income? Yes No

If yes, how much per month? $ Per year? $ _________ _

IDl. Ufe insurance Cash Value

Does resident have life insurance policies with cash values? Yes No

Approx. amount of cash value $ Annuities $ __________________ _

Company Name __________________________________________________ ___

Agent's name ________________ Agent's Tele # (_), ______ _

IE. Securi~ies

Does the applicant own stocks and bonds? _ Yes No

Approx. value of all securities $ __________________ _

Agent handling securities: Name

Address _________________________________ ___

Tele # (_) _____ _

Accord ing to the best of my knowledge, the foregoing information is accurate and true in all respects. I agree, if admitted, to abide by the regulations of the New Jersey Firemen's Home.

Signature of Applicant and/or Signature of Person Acting for Applicant

Date Address

Tele# Relationship

5

Month Year Application for Admission Revised. 07 2012

SAMPLE

Prepared by; THOMAS H. WARD, ESQUIRE Solicitor, New Jersey Firemen's Home

AGREEMENT TO REIMBURSE

THIS AGREEMENT made this_ day of _________ in the year of our Lord Two Thousand

and between hereinafter called the applicant and

___________ spouse and/or family of said applicant, part(y)(ies) of the first part, and the

Board of Managers of the New Jersey Firemen's Home.

The following is an agreement concerning the reimbursement of the Firemen's Home for all services and boarding provided by the Home for the benefit of its Guest.

A. By execution of th is document and admission to the Home, the Guest and his/her estate agree to be obligated to pay all sums due the Firemen's Home for the care of the Guest.

B. All income which the Guest may entrust to the Home by means of Power of Attorney or assignment may be used for payment or reimbursement of any costs incuned or advanced by the Home on behalf of the Guest.

C. The guest shall be responsible for the maintenance fee as may from time to time be established by the Board of Managers ofthe New Jersey Firemen's Home.

D. Execution of th is document shall constitute penn iss ion to the Home physician to obtain all medical information respecting the Guest from any source.

E. The Guest or his/her estate shall be absolutely responsible for all costs incuJTed by the Home on behalf of the Guest. This responsibility shall be present regardless of Medicare eligibility or other medical reimbursement plans.

F. A quarterly statement will be issued for each quarter which shall show all deposits to and withdrawals from the Guest's account.

G. The present monthly maintenance fee is $850.00 and is payable upon entry into the Home and then monthly thereafter.

1-:L If suflicient or excess funds remain in the Guest's medical account, the interest accrued from the invested monies will be transfened to the General Account and used to operate the Home. STATE STATUTE- 30:4-67-·l Eff. June 14, 1938

I, , say that all facts, matters, and things set forth in the foregoing application are true to the best of my knowledge and belief.

Witness:

Applicant's Signature Dated: ------

Signature of Spouse/Family

Relationship to Applicant

Revised 2016

SAMPLE

!.IMITED DURABLE POWER OF ATTORNEY

KNOW ALL MEN BY THESE PRESENTS:

That I, , referred to herein as principal, now a Guest of the New Jersey Firemen's Home, 565 Lathrop Avenue, Boonton, New Jersey, 07005, designated the Superintendent or Treasurer of the New Jersey Firemen's Home as my attorney in fact and agent (thereinafter called "Agent") in my name and for my benefit.

1. Limited Grant of Power. To do each and every act which I could personally do for the following limited uses and purposes: A. to endorse and negotiate all checks, drafts, pension payments, Social Security checks, supplemental

Social Security income or other income payments received by Guest at the New Jersey Firemen's Home. B. to review and approve quarterly accounting reports of the Guest as issued by the New Jersey Firemen's

Home. C. to complete, endorse, execute and take all steps necessary for the processing of all medical insurance or

reimbursements claims to Medicaid, Medicare, Blue Cross Blue Shield of New Jersey or any private or public health insurance plan in which the Guest is participating.

D. to manage and distribute a personal allowance to the Guest from any funds entrusted to the Home on behalf of the Guest in such amounts as determined by the appropriate officers of the Home.

E. to apply for assistance to the Local Firemen's Relief Association in the fire district or municipality where the Guest resided . This assistance shall be applied to the Guest account held by the Home and be utilized for medical expenses of the Guest.

F. in the event my medical needs are of such a nature to require a different medical facility than the New Jersey Firemen's Home, I authorize the Superintendent to direct my transfer and treatment to a medical facility appropriate for my medical needs and for the Superintendent to have the full power to make all medical decisions as my Power of Attorney while I am a guest at the medical facility. This power shall include the power of the Superintendent of the New Jersey Firemen's Home to make medical decisions concerning my care and treatment. ·

THIS POWER SHALL SPECIFICALLY NOT APPLY TO PROPERTY, REAL OR PERSONAL, POSSESSED OR MAINTAINED BY THE GUEST OUTSIDE THE HOME.

2. Interpretation and Govern.Lo.g__1_aw. This instrument is to be construed and interpreted as a durable power of attorney. The enumeration of specific powers herein is intended to limit and restrict the powers herein granted to my Agent. This instrument is executed and delivered in the State of New Jersey and the laws of the State of New Jersey shall govern all questions as to the validity of this power and the construction of its provisions.

3. Third-Party Reliance. Third parties may rely upon the representatives of my Agent as to all matters relating to my power granted to my Agent, and no person who may act in reliance upon the representations of my Agent or the authority granted to my Agent shall incur any liability to me or my estate as a result of permittin g my Agent to exercise any power. Any third party may rely on a duty executed counterpart of this instrument, or a copy certified by my Agent to be a true copy of this original hereof, as full y and completely as if such third party had received the original of this agreement.

4. Disability of Principal. N.J. S.A. 46:2B-8 authorizes me to provide that this power of attorney shall not be affected by my disability as principal and I declare this power of attorney shall not terminate upon my disability. The power(s) conferred by this document shall be exercisable from this date notwithstanding a later disability or incapacity on my part and shall be val id until such time as I shall die or revoke this power.

IN WITNESS WHEREOF, I have herein set my hand and seal this day of _____ , 20 .

Sworn to and Subscribed before me this __ day of , 20_. Signature of Guest

Notary Public, State of __ _

7

SAMPLE

New Jersey Firemelf]1S Home 565 l01~hlrrop Avenue, Boof!1l~Oii1l, NJ 07005

{g7J) 3J4c0024

MEDiCAl <CIERl~F~CAT~ON OF lOCAliPHYS~<C~AN

NAME: __________ _ AGE DATE: _ ______ _

PHYSICAL EXAMINATION:

!Eyes: __ - (Visual Diagnosis, i.e., Glaucoma, macular degeneration, lens replacements)

lEans: - (Hearing conditions, hearing aids)--------------------­

Moutlh, Nose & Tlhlrroaft: - ---------- ----- ------- --­

Necllc Thyroid __ Glands ___________ _

l~ fl1lgs : _________ _

BP ___ _ Pulse ___ _ Heart - - --Size -----Murmurs -- Rhythm _ __ _

Varicose Veins _______ _ Peripheral Circulation ________ _

Abdomef!1l:General __________________________ _

Hernia Varicocele -------- Hydrocele ______ _

Ex~rremities: Amputations_ Edema ______ _ Gait ____ _

Stasis Dermatitis Ambulatory ____ _ Weight Bearing _____ _

Spine a01dl Joints: ----------------------------

Skin Rashes Good Bed Sores ---- ---- ----Assistance: -------!Food: Independent Eating: ______ _

Diet: ________________ ___ ___ _________ _

Allerrgies: Medication -------------------------Food & Environmental

------------------~---

Have you lbeerril hospitalized within the iast yearr: Yes No

If YES, when to where -------------what for ------------------- --- ------------Medications: (Presently taking and why)

8

Month Year Application for Admission Revised. 07 2012

SAMPLE

(Continued)

!Hlalbli~§: Alcohol Tobacco ------- Drugs ____ _

IREVIEW O!F SYSTIEM§

!C<llrrdiov<a!Scl!JJ~<llr: RHD CHF ____ _ Hypertension ____ _

Myocardial Infarction Other-------------------

!Respirra~o~: Asthma ____ Emphysema __ Chronic Bronchitis _ __ _

Previous TB Date of last chest x-ray Result:

Gas~m - GB Disease Ulcer

~ntesU81la!: Recurrent or cl1ronic Hemorrhoids

Bowel habits, regular Constipated

Genito ~ Pyelonephritis . Calculi Cystitis Uri1111ary:

Muscuio ~ Rheumatoid Arthritis Osteoarthritis Osteoporosis Sk:eieta~:

Sig nifica1111~ injuries: _______ _

!Previous Vascularr Accndei11t: Thrombotic Hemorrage _ Undetermined

Otlhiell" DisorOJerr: -----------------------------

!Endocrine: Diabetes

Additioll1lai !nformatnoll1l :

Thyroid Problem_ Other ____________ _

Date Signature of Physician

* REMINDER TO THE APPliCANT* !111l adldi~iollll ~o ~lhiese Medical Certification of Locai Physician Forms it is mandatory that a Neuli"oiogkZJ! IEvah.JJatioiil Z~nd a !Psychiatric IEvaluatioro foe perforrmerol by a prrofessiona! Neumiogistt am;IJ a pmfessiornai Psychiatrist The evaiuatnons a!l"e tto be ty!Pedl all1ld si!JliblmiUedl oll1l tlhle prrofessnoli1al's IEvahJJa~tioll1l !Form (the New Jersey 1Firremell1l's Home does not SILJJfP[pliy Une eva~!I!JlZJtnoll1l foli"ms}.

9

Application for Admission Month Year

Revised.· 07 2012

SAMPLE

*** DRAFT ***

EXAMPLE- PSYCHIATRIC EVALUATION

NOTE: ALL EVALUATIONS MUST BE TYPED AND PLACED ON PHYSICIAN/ FACILITY LETTERHEAD OR_ THEY WILL NOT BE ACCEPTED. EMERGENCY ROOM

EVALUATIONS WILL NOT BE ACCEPTED.

Month/Day/Year

New Jersey Firemen's Home Attn: Superintendent 565 Lathrop Avenue Boonton, NJ 07005

Dear Sir: RE:

This is an elderly white widowed male, who was first seen by me on depressed.

1994, as the patient was

The patient is a resident of and he was referred from the nursing home as the patient was expressing depression and suicidal comments.

HISTORY OF PRESENT ILLNESS: This elderly white gentlemen ' s wife had died in December of 1993 and in March of 1994 the patient underwent a right below knee amputation. After the surgery the patient started getting depressed. He was not doing well , he was withdrawn, would not take care of his ADL's and hence he was referred to me.

The patient, however, denied suicidal ideations to me at that time. He was started on Paxil 20mg orally at bedtime and Xanax was discontinued and he was started also on Ativan 0.25mg orally three times a day.

On subsequent evaluations, on 6- I 5-94, the patient apparently was doing well, responding well to Paxil. The patient since then has been subsequently followed by me. His last evaluation was on 4-24-95, at the time of evaluation the patient appeared to be doing fairly well. He was, in a way, hypertalkative, a good historian and related well. Casually groomed. Mood appeared to be euthymic. Affect appeared to be appropriate. I did not detect any signs of psychosis. He was alert and oriented times three. No suicidal or homicidal ideation's. He knew the year, month, date. I did not detect any paranoia or any guardedness . Memory and cognitively he remained unchanged since the first evaluation, he was doing fairly well. Insight and judgment of his problems appeared to be fair.

IMPRESSION:

PLAN:

application for admission

AXIS 1:

AXIS II: AXIS III:

MAJOR DEPRESSION, MODERATE, WITHOUT PSYCHOTIC FEATURES. NONE. RIGHT BELOW KNEE AMPUTATION.

At this time I consider the patient to be pretty stable . He is apparently responding very well to Paxil, on 40rng ofPaxil and Ativan 0.25mg orally twice a day. The patient was given an appointment to see me in 6 weeks time. I do not detect that there can be any problems with the patient at the nursing home.

If there are any questions regarding this, please contact me at my office.

Sincerely yours,

(Physicians Signature)

Month Year Revised: l1 2013

SAMPLE

*** DRAFT ***

E~AMPLE - NEUROLOGICAL EXAM

NOTE: ALL EVALUATIONS MUST BE TYPED AND PLA CED ON PHYSICIAN/ FACILITY LETTERHEAD OR THEY WILL NOT BE ACCEPTED. EMERGENCY ROOM

~VALUATIONS WILL NOT BE A CCEPTED.

New Jersey Firemen 's Home Attn: Superintendent 565 Lathrop Avenue Boonton, NJ 07005

Dear Sir:

Month/Day/Year

RE:

This is an year old, white male who has been diagnosed with Parkinson' s Disease, although it is unclear when, who now is referred for neurologic evaluation prior to entering the Firemen 's Home in Boonton, NJ. The patient is accompanied by hi s nurse who states that he has been confused and agitated at night, sleeps during the day and is awake during the night, and for this reason he has begun on Restoril and Elavil. The patient has a past history of colostomy for an intestinal perforation in 1987, hypertension, congestive heart failure, ASHD and Parkinsonism. His medications include Lanoxin, Haldol, aspirin, Elavil , Restoril, Bumex, Cardizem, Metamucil, MOM, Lotrisone cream and Otocort. The patient is unable to give me any additional history and previous medical records are unavailable aside from a brief letter from his family physician . Patient does not complain of headaches, diplopia, weakness, numbness, tingling or speech difficulty. He is ambulatory at times but does have difficulty with balance and walking.

The patient is awake and ale1i. He is oriented to locations. He knows that he is in , NJ. He is oriented to year but disoriented to month and day, stating that is. He can name the current president by no previous presidents. He can spell a five-letter word forward but not backwards. He is able to calculate that there are 20 nickels in a dollar and that 60 nickels equal three dollars. He remembers two out of three objects after ten minutes.

On cranial nerve exam, the pupils are equal and reactive to light. Extraocular movements are full without nystagmus or diplopia. Visual fields are full to confrontation. Fudni are benign. Facial sensation and symmetry are intact. The tongue is midline. The palate moves symmetrically. Motor strength is 5/5. There is cogwheel rigidity noted bilaterally in the upper extremities. There is no tremor noted. The reflexes are 2+ and symmetrical. Plantar responses are flexor. The gait can not be tested . Coordination appears grossly intact. There is a positive snout reflex. A right pulmimental reflex and a negative grasp reflex. The patient exhibits a mask like facies and brady frenia and brady kynesia.

My impression is that the patient has a dementia but it is unclear whether a work up has been performed and I would recommend obtaining a CAT scan of the brain with contrast, B12, Folate level, VDRL as further evaluation of his dementia. A T4 was provided with his records, which is within normal limits. If the patient is diagnosed to have Alzheimer 's Disease, I would recommend instituting therapy with Cognex, 1 Omg QID and monitoring weekly SGPT, as he appears to have a very mild dementia at the present time and would be a good candidate for therapy with Cognex. I would recommend strongly discontinuing the Elavil and Restoril in particular the Restoril, which is a Bendsodiazapien and will increase confusion in the elderly and in dementia patients. I feel in addition his Haldol should be discontinued because of the potential of Parkinsonian symptoms related strictly to Haldol. I would recommend substituting Mellaril 25mg or 50mg

11 Month Year

application for admission Revised. ll 2013

SAMPLE

** * DRAFT ***

EXAMPLE- NEUROLOGICAL EXAM - Continued

at bedtime and 25mg as needed during the day for any agitation which the patient may exhibit. Mellaril will , cause fewer potential side effects and Parkinsonism compared to Haldol. If after switching this medication

the patient remains Parkinsonism I would recommend beginning Sinemet CR, 1 tab PO BID with a later addition of Eldepryl for control of his Parkinsonism symptoms, which also appear to be relatively mild to moderate at the present time.

At the present time his diagnosis is Parkinsonism and Dementia. It is unclear whether these are strictly related to medications which he is receiving which could cause both confusion and Parkinsonism symptoms or whether these do represent true Alzheimer' s Disease and Parkinson' s Disease.

If you require any further information, please do not hesitate to contact this office.

Sincerely yours,

(Physicians Signature)

H is mandatory that all applicants submit current (within the last six months) Neurological and Psychiatric Evaluations with their Application for Admittance for the Medical Director's review. Aforementioned evaluations must be typed! and signed by the doctor performing the evaluation.

Month Year application for admission Revised: II 20I3

SAMPLE

Department of Humallll. §ervkes

Division of Aging Services

Office of Community Choice Options

Instruction for the Pre-Admission Screening and Resident Review(PASRR) Level 1 Screen

A. Section I - Demographics_:tnd OCCO Status

1. Name: give individuals full name, last name and first name. 2. Social Security number: individuals full social security number. 3. Cunent location address: where the individual is when completing the PASRR form. 4. County of Current Location: County where individual is located when filling out the PASRR form. 5. Date of Birth: self-explanatory. 6. Cunent Location Setting: where the individual is when the P ASRR form is filled out (hospital,

community, home etc.) Check one. 7. NF Applicant Status Box: Check applicable PAS status.

B. Section II - Mental Illness Screen Question 1: Does the individual have a diagnosis or evidence of a major mental illness? Answer yes or no and specify Diagnosis and include any current substance-related disorder diagnosis if answered yes. Question 2: Has the individual had a significant impairment in functioning related to a suspected or known diagnosis of mental illness? Check the boxes of all that apply for 2a, 2b, 2c, and record yes if any of the three subcategories are checked. Question 3: Within the last 1:\¥0 years has the individual : Check the boxes for 3a, 3b and record yes if either/both of the two subcategories are checked. If yes is checked explain and provide dates .

C. Section II Screening Outcome for Questions 1 through 3 Complete this section for all the Questions 1 through 3, Check one outcome only.

a. Check the box for a Positive Screen MI if all questions 1 through 3 are answered yes. b. Check the box for a negative Screen MI with any combination ofNO for questions 1 through 3.

D. Section III - Mental Illness Primary Dementia Exclusion This exclusion only applies to individuals who have a confirmed primary diagnosis of dementia and that the dementia diagnosis is documented as primary or more progressed than a co-occurring mental illness. This section is only completed if Section II Screening Outcome is Positive Screen for MI.

a. Question 4: If a diagnosis of dementia is present, place a check beside any/all that apply to questions 4a, 4b, and 4c.

1. Provide the DSM-S code for the dementia diagnosis. ii. Complete the Dementia diagnosis made on the basis of: check all that apply.

iii. Has the physician documented Dementia as the primary diagnosis or that the Dementia is more progressed than any co-occurring mental illness diagnosis: answer yes or no per MD documentation.

E. Section III Screening Outcome for MI Primary Dementia Exclusion Question 4: Complete this section for Questions 4. Check one outcome only.

a. Check the Yes box for Primary Dementia Exclusion if all responses to question 4a-4c are yes. b. Check the No box for Primary Dementia Exclusion is any response to questions 4a-4c are no.

LTC-26 Instructions MARlS

S'"r'

Page 1

SAMPLE

Department of Human Services

Division of Aging Services

Office of Community Choice Options

JF. Section IV Intellectual Disability/ Developmental Disability/Related Conditions Screen Question 5: The definition of an Intellectual Disability (ID) is a significantly decreased level of intellectual

functioning measured by a standardized, reliable test of intellectual functioning and encompasses a wide range

of conditions and levels of impairment with concurrent impairments in adaptive functioning. The ID must have manifested prior to the age of 18. The question asks if the individual has a current diagnosis or a history of intellectual disability with an onset prior to age 18 yes of no.

Question 6: The definition of a Related Conditions (RCs) is severe, chronic developmental disability, but not forms of intellectual disabilities, that produce similar functional impairments and require similar treatment or services. RCs must have manifested prior to the age of 22. The question Does the individual have a current diagnosis, history or evidence of a related condition that may include a severe, chronic disability with date of onset prior to age 22 that is attributable to a condition other than mental illness that results in impairment of general intellectual functioning or adaptive behavior, mobility, self-care, self-direction, learning, understanding/use oflanguage, capacity for independent living (e.g., autism, seizure disorder, cerebral palsy, spina bifida, fetal alcohol syndrome, muscular dystrophy, deaf or closed head injury). Answer yes or no. Question 7: Does the individual receive services or previously received services paid through the Division of Developmental Disabilities. Answer yes or no.

Question 8: The question is seeking to know if a referral was made from an agency that serves individuals with ID\DD\RC yes or no and if yes from what agency.

G. Section IV Screening Outcome for Questions 5 through 8 Complete this section for all the Questions 5 through 8, Check one outcome only.

a. Check the box for a Positive ID/DD if any responses to questions 5 through 8 are yes. b. Check the box for a negative screen if ALL responses to questions 5 through 8 are no.

H. Section V - PASRR Final Level I Screening Outcomes and Referral, if Indicated) Step 1: Determine Screening Outcome for Sections II and III. Check one response for each section. Step 2: Determine Final Levell Screening Outcome. Check only one screening outcome for this step and follow the directions if the screen is positive to forward the referral to the applicable agency(ies) DMAHS and/or DDD.

I. Section VI - Categorical Determinations for Level I Positive Screens If you are requesting a categorical determination for the Positive PASRR Level I Screen you must check the box beside the appropriate condition/circumstance, and contact DDD/DMHAS as applicable. DMHAS has a categorical determination form that will need to be completed for a categorical determination. A link to this form is in this section on the P ASRR Level I Screen.

H. Section VII - 30-Day Exempted Hospital Discharge for Level I Positive Screens Hospital Exemption applies only to initial nursing facility admission; it does not apply to resident review for change in condition, nursing facility readmission or inter-facility transfer. The individual must meet the following criteria to be considered for a P ASRR Level I 30 Day Exempted Hospital Discharge:

LTC-26 Instructions MARlS Page 2

SAMPLE

Department of Human §erviices

Division of Aging Services

Office of Community Choice Options

1. The individual has received inpatient non psychiatric care at an acute C9.re hospital; and

2. The individual requires skilled nursing services for the condition which he or she received care "in the

hospital; and

3. The hospital physician certifies before the NF admission that the individual is likely to require less than 30 days skilled nursing facility care.

4. The PASRR Level I form is then faxed to DMHAS and/or DDD and OCCO prior to the individual being discharged to the NF.

5. This section must be signed by the hospital physician that is certifying the Level I Hospital Exempt Discharge or it will not be processed.

I. Section VIII - P ASRR Level I Screening Outcome and Certification of Screening Professional Completing the Level I Form.

1. Outcome of Level I Screen box: check applicable outcome box. 2. Name of Provider/agency/program box: fill in provider name and /or agency/ program where the

P ASRR form is being completed. 3. Name of Screening Professional: print name of person completing the form. 4. Title of screening professional: print your title . 5. Screening Professional phone number: phone number where you can be reached if additional

information is needed. 6. Screening Professional Fax: number where the reviewed PASRR is to be faxed. 7. Signature of Screening Professional: Signature of person completing the form. 8. Date: Date form is faxed to the OCCO regional office .

All Positive PASRR Level I Screens are to be faxed to OCCO and DDD and/or DMHAS as applicable. All Positive P ASRR Level I Screens certified by the physician as a Level II 30-Day Exempted Hospital discharge need to be faxed to OCCO and DMHAS and/or DDD as applicable prior to the individual being discharged to the NF.

J. Section IX- Required Contact information for All Positive Level I Screens This section is to be completed on every positive Level I screen. If this section is blank the Level I screen cannot be processed. This section allows for the determination of the Level II authority to be sent to the referring Entity, consumer, Legal Representative, if applicable, Family member if permission is received from the individual, and the attending physician.

K. Section VIII - Contact InfoJ[.ll!lation This section contains the phone and fax numbers for the local OCCO/DMHAS/DDD agencies where the completed PASRR Positive Level I Screens are to be sent. This section must be completed with all contact information prior to submission to the level II authority as applicable for all positive screens.

LTC-26 Instructions MARlS Page 3

SAMPLE

NEW JERSEY DEPARTMENT OF HUMAN SERVICES

PRE-ADMISSION SCREENING AND RESIDENT REVIEW (PASRR) LEVEL I SCREEN

• Please print and complete all questions. • This form must be completed for all applicants PRIOR TO nursing facility admission in accordance with Federal PASRR Regulations

42 CFR § 483.106. • All Posit ive Level I Screens are to be faxed to the appropriate agencies including OCCO (Office of Community Choice Options) a1nd

also to DOD (Division of Developmental Disabilities) and/or OM HAS (Division of Mental Health and Addiction Services), as applicable. • All 30-Day Exempted Hospital Discharge Screens are to be faxed to OCCO and ODD and/or DMHAS, as appl icable. . • For first time identification of Ml (Mental Illness) and/or ID/DD/RC (Intellectual Disability/Developmental Disability/Related Condition), the Level 1

Screener must provide written notice to the applicant and/or their legal representative that Ml and/or ID/DD/RC is suspected or known and that a referral is being made to DMHAS and/or DOD for a PASRR Level II Evaluation . The referral notice for a PASRR Level II Evaluation Letter (L TC-29) can be downloaded from the New Jersey Department of Human Services' Division of Aging Services forms web page at http://www.state.nj.us/humanservicestdoas/home/forms.html .

• FAILURE TO ABIDE BY PASRR RULES WILL RESULT IN FORFEITURE OF MEDICAID REIMBURSEMENT TO THE NF DURING PERIOD OF N()N-GOMPLIANCE INACCORDANGEWITH FEDERAL PASRR REGULATIONS 42 GFR 483.122.

SECTHON 1- DEMOGRAPHICS AND OCCO PAS STATUS Name of Applicant (Last Name, First Name) Social Security Number

Current Location Address I County of Current Location Date of Birth

Current Location Setting

D Acute Care Hospital D Home/Apartment D Res idential Health Care Facility D Group Home/Boarding Home D Psychiatric Hospital/Unit D Assisted Living Residence D Other (Specify) :

OCCO PAS Status

D Current PAS on File, PAS Date: D Referred to OCCO for PAS, Referral Date:

D Private Pay D Other (Specify):

SECTION 11- MENTAL ILLNESS SCREEN

1. Does the individual have a diagnosis or evidence of a major mental illness limited to the following disorders: schizophrenia, schizoaffective , mood (bipolar and major depressive type) , paranoid or delusional, panic or other severe anxiety disorder; somatoform or paranoid disorder; personality disorder; atypical psychosis or other psychotic disorder (not otherwise specified}; or another mental disorder that may lead to chronic disability? .... . ....... . ... ..... . .. .. ... .. ... ...... . ........ ..... .. D Yes 0No

Specify Diagnosis(es) based on DSM-5 or current lCD crite ria and include any current substance-related disorder diagnosis(es):

2. Has the individual had a significant impairment in functioning related to a suspected or known diagnosis of mental illness (record YES if ANY of the three subcategories below are checked}? .... .... ... . ........... ... ..... . .. . ...... . ... . .. ....... ... .. 0 Yes 0No

Check all that apply:

a.D Interpersonal functioning. The individual has serious difficulty interacting appropriately and communicating effectively with other persons, has a possible history of altercations, evictions, unstable employment, fea r of strangers, avoidance of interpersonal relationships and social isolation.

b.D Concentration, persistence, and pace. The individual has serious difficulty in sustaining focused attention for a long enough period to permit the completion of tasks commonly found in work settings or in work-like structured activities occurring in school or home settings, difficulties in concentration, inability to complete simple tasks within an established time period, makes frequent errors, or requires assistance in the completion of these task.

c.D Adaptation to change. The individual has serious difficulty in adapting to typical changes in circumstances associated with work, school, family or social interactions, agitation, exacerbated signs and symptoms associated with the illness or withdrawal from situations, , self-injurious, self-mutilation, suicidal , physical violence or threats, appetite disturbance, delusions, hallucinations, serious loss of interest, tearfulness, irritabi lity or requi res intervention by mental health or judicial system.

3. Within the last 2 years has the individual (record YES if EITHER/BOTH of the two subcategories below are checked): .... DYes 0 No

a. D experienced one psychiatric treatment episode that was more intensive than routine follow-up care (e.g ., had inpatient psychiatric care: was referred to a mental health crisis/screening center; has attended partial care/hospitalization; or has received Program of Assertive Community Treatment (PACT) or integrated Case Management Services); and/or

b. D due to mental il lness, experienced at least one episode of significant disruption to the normal living situation requiring supportive services to maintain functioning whi le living in the community, or intervention by housing or law enforcement officials?

If yes, explain and provide dates:

LTC-26 SEP 15 PAGE 1 OF 5

l

SAMPLE

PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) LEVEL I SCREENING TOOL- CONTINUED

Name of Applicant (Last Name, First Name) I Social Security Number

SECTION Ul SCIREENIN1G OllJTCOME for MB Screen Questioll1ls "l through 3 (check C)ll1le oiUitcome o1111Uy)

D Positive Screen Ml If AU .. Questions 1 through 3 are answered VIES, screen is Positive for MI. Continue on to Section Ill to determine if Ml Primary Dementia Exclusion applies.

D Negative Screen Ml If Questions 1 through 3 are answered with any combination of NO, screen is Negative for

MI. Skip to Section RV for ID/DD/RC Screen.

SECTION m- MENTAIL DULNESS PRIMARY DEMENTRA EXCII..USION (complete this section only if Section 10 Screening Outcome us Positive ifor Scrreell"'l1ior MD

4. The Mental Illness Primary Dementia Exclusion applies to individuals who have a confirmed diagnosis of dementia and that the dementia diagnosis is documented as primary or more progressed than a co-occurring mental illness.

a. Does the individual has a diagnosis of dementia (including Alzheimer's Disease or related disorder) based on criteria in the DSM-5 or current version of the lCD? .. .... ...................... .. .......... .. .... .. .. .. .. .... .. .. ... .... .. ........ .. ............... .. .... . DYes DNa Specify DSM-5 or lCD Codes(s):

b. Were any of the following criteria used to establish the basis for a Dementia diagnosis? Record Yes if any or all of the following criteria apply and are checked off: ........... ........ ...... . .. ........................... ............ ..... .............. ..... .. ...... ... .. .... DYes D No

D Mental Status Exam D Neurological Exam D History and Symptoms D Other Diagnostics (specify):

c. Has the Physician documented dementia as the primary diagnosis OR that dementia is more progressed than a co-occurring mental illness diagnosis (explain how dementia as primary/more progressed was documented and verified)? ... .... . DYes D No:

SECTION Ill SCREENING OU'TCOME for Ml Primary Dementia Exclusioll"'l Question 4 (check one outcome only)

D YES - Ml Primary If A~J, responses to Questions 4a-4c are YES, outcome is VIES for the Ml Primary Dementia Exclusion Dementia Exclusion. Continue on to Section IV for 10/DD/RC Screen.

D NO- Ml Primary If ANY responses to Questions 4a-4c are NO, outcome is NO for the Ml Primary Dementia Exclusion Dementia Exclusion. Continue on to Section IV for ID/DD/RC Screen.

SECTION IV -INTELLECTUAL DISABILITY/DEVELOPMENTAL DISABILITY/RELATED CONDITIONS SCREEN

5. Intellectual Disability (ID) is a significantly decreased level of intellectual functioning measured by a standardized, reliable~ test of intellectual functioning and encompasses a wide range of conditions and levels of impairment with concurrent impairments in adaptive functioning. The ID must have manifested prior to the age of 18. Does the individual have a current diagnosis or a history of Intellectual disability (mild, moderate, severe or profound) and/or is there any presenting evidence (cognitive or behavior characteristics) that may indicate the person has an intellectual disability with date of onset prior to age 18? .......... ............ ...... ........ .... ... .... .... ........ .... ...... ............... ...... .. . DYes DNo If yes, explain:

-6. Related Conditions (RCs) are se~vere, chronic developmental disabilities, but not forms of intellectual

disabilities, that produce similar functional impairments and require similar treatment or services. RCs must have manifested prior to the agE! of 22. Does the individual have a current diagnosis, history or evidence of a related condition that may include a severe, chronic disability with date of onset prior to age 22 that is attributable to a condition other than mental illness that results in impairment of general intellectual functioning or adaptive behavior, mobility, self-care, self-direction, learning, understanding/use of language, capacity for independent living (e.g., autism, seizure disorder, cerebral palsy, spina bifida, fetal alcohol syndrome, muscular dystrophy, deaf or closed head injury)? ... ......... ... ........ ..... .. . DYes D No If yes, explain:

7. Does the individual currently receive services or previously received services paid through the Division of Developmental Disabilities (e.g ., day habilitation, group home, case management, Community Care Waiver, Real Life Choices, Family Support of Self Determination) or other agency? .. ... ...... ... ..... .... .. ............ .... ...... ... .... .. ....... ....... ........... ... .... ... ..... ................ .... .. ....... .. .. . DYes DNo

8. Was a referral made from an agency that serves individuals with ID/DD/RC past? ... .... ........... .... .......... ....... ..... ...... ...... DYes DNo

If yes, referred from what agency? .

SECTION IV SCREENING OUTCOME for ID/DD/RC Screen Questions 5 through 8 (check one outcome o1111By)

I D Positive Screen ID/DD/RC l:f ANY responses to Questions 5 through 8 are YES, screen is Positive for ID/DD/RC

\ D Negative Screen ID/DD/RC If All responses to Questions 5 through 8 are No, screen is Negative for ID/DD/RC

LTC-26 SEP 15 PAGE 2 OF 5

SAMPLE

PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) LEVEL I SCREENING TOOL- CONTINUED

Name of Applicant (Last Name, First Name) I Social Security Number

SECTION V- PASRR lEVEL D SCREENING OUTCOME AND REFERRAL, UF INDICATED

STEP 1. Determine Screening Out,comes for Sections 11, m and OV (check ONE response for EACH Section):

D Positive Section II - Ml Screen

D Negative

D Yes Section Ill - Ml Primary Dementia Exclusion

0 No NOTE: check N/A if Section Ill was skipped O N/A due to Negative Ml Screen

D Positive Section IV- 10/DD/RC Screen 0 Negative

STEP 2. Determine Final Level B Screening Outcome (check ONE final screening outcome only):

If Step 1 Section II Negative D Negative Screen Section Ill N/A Admit to NF

Section IV Negative If Step 1 Section II Positive

D Negative Screen Section Ill Yes Admit to NF Section IV Negative

Positive Screen If Step 1 Section II Posit ive

Refer to DMHAS (unless eligible for 30-Day D Section Ill No

Ml Only Section IV Negative

Exempted Hospital Discharge, see Section VII)

Positive Screen If Step 'l Section II Negative

Refer to DDD (unless eligible for 30-Day Exempted D Section Ill N/A

ID/DD/RC only Section IV Positive

Hospital Discharge, see Section VII)

Positive Screen If Step 1 Section II Pos itive

Refer to both DMHAS and DDD (unless eligible for D Section Ill No

Ml and 10/DD/RC Section IV Positive

30-Day Exempted Hospital Discharge, see Section VII)

./ Positive screening outcomes require referral to the applicable agency(ies) - DMHAS and/or ODD- prior to NF admission unless requesting a 30-Day Exempted Hospital Discharge (see Section VII) .

./ Complete Section VI if requesting a Categorical Determination for individuals with positive screens .

./ When screening outcome is positive, also forward a copy of this form to the OCCO Regional Office serving your area (see page 5).

SECTION VI- CATEGORICAL DETERMINATION FOR LEVEL I POSITIVE SCREENS

If the Level I Screener is requesting an abbreviated Categorical Determination based on any one of the following four categories? Record Yes if any one of the following four categories apply and are checked off .. ..... ....... .. ... ......... ....... DYes D No Place a check in the box for the appropriate condition or circumstance:

D Terminal Illness D Severe Physical Il lness D Respite Care D Protective Service (APS)

DMHAS: Visit DMHAS website for C;:~tegorica l Determination Form http:/lwww.state.nj.us/humanservices/dmhs/home/forms.html. ODD: Contact ODD Regional Office serving your area (see Page 5).

SECTION VII - 30-DAY EXEMPTED HOSPITAL DISCHARGE FOR LEVEL I POSITIVE SCREENS

30-Day Exempted Hospital Discharge applies only to ~ITIAL nursing facility admission NOT resident review, nursing facilit~ readmission or inter-facility transfer. Complete this section for all Positive Screens meeting the following criteria.

EXEMPTED HOSPITAL DISCHARGE - An individual may be admitted to a skilled nursing faci lity directly from the hospital after receiving inpatient care (non-psychiatric) at the hospital if:

./ the individual requires skilled nursing facility services for the condition for which he/she received care in the hospital AND

./ the attending hospital physician certifies before the NF admission that the individual is likely to requi re less than 30 days ski lled nursing facili ty care.

Is the individual eligible for the 30-Day Exempted Hospital Discharge? .. .. ... ... .. ... .... ........ ..... .... .. ... .. DYes D No

Fax this completed form to OCCO and to DMHAS and/or DOD, as applicable, then the individual can be discharged to the nursing facility.

Name of Physician (Print)

LTC-26 SEP15

Signature of Physician Date

PAGE 3 OF 5

SAMPLE

PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) LEVEL I SCREENING TOOL- CONTINUED

Name of Applicant (Last Name, First Name) I Social Security Number

NURSING FACILITIES PLEASE NOTIE THE FOLLOWING IMPORTANT INFORMATION ABOUT 30-DAY EXEMPTED HOSPITAL DISCHARGES: • If the individual requ ires care beyond the initial 30-day period, the nursing facility must notify DMHAS and/or ODD, as

applicable, Qrior to the individual's 30th day in the NF, and must provide a written explanation of the reason for the continued stay including the anticipated length of stay.

• Federal regulations require that the PASRR Level II Evaluation and Determination be completed prior to the individual's 401h

day in the NF. • Admission under the above exemption does not relieve the nursing facility of its responsibil ity to ensure that specialized

services are provided to an ind ividual who has mental health or ID/DD/RC needs and who would benefit from those services. • FAILURE TO ABIDE BY PASRR RULES WILL RESULT IN FORFEITliRE OF MEDICAID REIMBURSEMENT F01R

NF SERVICES DURING PERIOD OF NON-COMPLIANCE IN ACCORDANCE Wl"'f'H FEDERAL PASR.R REGULATIONS 42 CFR 483.1~!2.

For first time identification ot= MI/10/DD, the Level I screener must provide written notice to the Nursing Facility applicant or legal representative that Ml and/or ID/DD/RC is suspected or known, and that a referral is being made to OM HAS and/or DOD for Level II Evaluation. The Referral Notice for a Level II Evaluation letter (L TC-29) can be downloaded from the New Jersey Department of Human Services' Division of Aging Services forms webpagt:l htt(;!://www.state.nj.us/humanservices/dmhs/home/forms.html.

SECTION VIII - PASRR LEVEL I SCREENING OUTCOME AND CERTIFICATION OF SCREENING PROFESSIONAL COMPLETING LEVEL I FORM

Outcome of Levell Screen (check ONE_ Negative or Positive Name of Provider/Agency/Program screening outcome)

0 Negative Screen

0 Positive Screen referring for Levell I Evaluation prior to NF admission (check one of the following boxes)

O MI 0 10/DD/RC 0 Ml & 10/DD/RC

0 Positive Screen 30-Day: Exem12ted Hos~itaD

Discharg~ (check one of the following boxes) OMI 0 10/DD/RC 0 Ml & 10/DD/RC

Attending hospital physician must certify Section VII. Fax completed form to OCCO, DMHAS and/or DOD, as applicable, then the individual can be discharged to the nursing facility.

0 Positive Screen Reguesting Categorical

Dete rmination referring for Level II Evaluation prior to NF admission (check one of the following boxes)

OMI 0 10/DD/RC 0 Ml & 10/DD/RC

Name of Screening Professional Complleting Form (print) Title of Screening Professional

Screening Professional Phone No. Screening Professional Fax No.

Signature of Screening Professional Completing Form Date

REMEMBER: ALL POS.TIV'I: PASRR LEVEL I SCREENS INCLUDING 30-DAY EXEMPTED

HOSPITAL DISCHARGES MUST

APPII..ICABLE. THANK YOU.

LTC-26 SEP15

BE fAXED TO OCCO AND ALSO TO DMHAS AND/OR ODD, AS

PAGE40F 5

SAMPLE

PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) LEVEL I SCREENING TOOL- CONTINUED

Name of Applicant (Last Name, First Name) l Social Security Number

SECTION OX- REQUIRED CONiiACil" DIMIFORMATOON FOR AILI!.. I?OS'Il'OVE ILIEVEO. U SCREENS 1. Name of Referring Entity (screening professional 's affiliation such as agency, hospital, NF, other healthcare provider, MCO, etc.)

Address I Street:

Town I Zip Code:

2. Consumer's Residing Address I Street (consumer's primary residence) Phone Number:

Town I Zip Code:

3. Name of Legal Representative (Last Name, First Name): Phone Number:

Address I Street:

Town I Zip Code:

4. Name of Family Member (if available and consumer or legal representative agrees to family Phone Number: contact/notification)

Town I Zip Code:

5. Name of Attending Physician: Phone Number:

Address I Street: Fax Number:

Town I Zip Code:

SECTION X- CONTACT INFORMATION

DIVISION OF MENTAL HEALTH AND ADDICTION SERVICES (IDMHAS)

DIVISION OF DEVELOPMENTAL DISABULUTIES (DDID)

IOIVISION OF AGING SERVICES (DOAS) - OFFICE OF COMMUNITY OPTIONS (OCCO)

Division of Mental Health and

Addiction Services (DMHAS)

Statewide PASRR Coordinator for Mental Health:

Phone 609-777-0482 or 609-777-0725; Fax 609-341-2307

LTC-26 SEP15

Division of Aging Services (DoAS)

Office of Community Options

(OCCO) RegionaB Offices

lllorthern Regional Office of Communitll Choice O~tions (NRO}: Bergen, Essex, Hudson, Hunterdon, Middlesex, Morris, Passaic, Somerset, Sussex, Union and Warren Counties Phone 732-777-4650; Fax 732-777-4681

Southern Regional Office of Communitll Choice O~tions (SRO}: Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, Mercer, Monmouth, Ocean and Salem Counties P'hone 609-704-6050; Fax 609-704-6055

Division of DevelopmentaO Disabilities (DDD) Regional Offices

Territory 1: Bergen, Essex, Hudson , Morris, Passaic and Sussex Counties Phone 973-693-5080; Fax 973-648-3999

Territory 2: Middlesex, Monmouth, Ocean, Somerset and Union Counties Phone 732-863-4500; Fax 732-863-4409

Territory 3: Burlington, Camden, Hunterdon, Mercer and Warren Counties Phone 609-292-1922; Fax 609-292-2629

Territorv 4: Atlantic, Cape May, Cumberland , Gloucester and Salem Counties Phone 609-476-5200; Fax 609-909-0656

PAGE 5 OF 5

SAMPLE

RESPONSIBiUT~IES OfF THE RESIDENT

I, _ _________________ , a resident of this facility, certify that I have

received a written copy of my obligations and responsibilities to the facility. I further cetiify that

my rights and responsibilities were reviewed with me and that I understand them and agree to

abide by them to the best of my ability.

Date

Date

(Signature - Resident)

or

(Signature -Agent/Power of Attorney For Resident)

A !COPY OfF TH#S DOCUMENT MUST BE FRIED #N THE RES#IDEN/1'£ MIED#ICAL RECORD

13 Month Year

Application for Admission Revised. 07 2012

SAMPLE

!R®~Ol©fli ©~ ~~® l©~~~ f!u"® C©mp~U111f ~U11©1/©r

IR®~~®lf A~~©~D~~ll©u1l

DATE OF REPORT ----

THE ________ ~~----~--------------------------- FIRE COMPANY (Name of Fire Company)

OF THE FIRE DEPARTMENT OF - - ---- -

AT A MEETING HELD ----·-- DOES HEREBY CERTIFY - ---------­(Name of Appl icant)

THAT THE FIRE DEPARTMENT IS UNDER MUNICIPAL CONTROL, AND THAT THE RECORDS

HAVE BEEN EXAMINED AND SHOW THAT THE APPLICANT WAS AN ACTIVE MEMBER OF

SAID FIRE DEPARTMENT FOR A MINIMUM OF ONE (i ) YEAR HAVING BEEN ADMITTED AS

AN ACTIVE MEMBER ON - ------- -- , AND RETIRING FROM ACTIVE SERVICE

THROUGH ON _____ ; AND THAT SAID APPLICANT IS A (Resignation or Suspension) (Date)

PROPER PERSON TO BE ADMITTED TO THE FIREMEN'S HOME AND OF GOOD MORAL

CHARACTER AND IN GOOD STANDING AS A FIREMAN.

CIERnFEIOJ IBN n~E lOCAliFIIRIE COMPANY

PRESIDENT (Print Name) : ________ (SIGNATURE}:

PHONE: ( _ _) ___ _ _ _ _

SECRETARY (Print Name): _

PHONE: ( _ _)

------ (SIGNATURE)): _________ _

CERTIFIED BY THE LOCAL FIREMEN'S RELIEF ASSOCIATION

TRUSTEES:

lOCAliREU EIF ASSOCiATION:

PRESIDENT (Print Name):-------- (SIGNATURE):----------

PHONE: (_) ______ _

SECRETARY (Print Name): ------ (SIGNATURE):----------

PHONE: (_)_ _____ _

RE Ll E F ASSO C IAT I 0 N .-=-:-:-=-:-:--:-c:----:-~-:: PRIN I NAME OF ASSOCIA liON

COUNTY __ _

14 lJ12!':.!l?: Year

Application for Admission Revised. 07 201/

SAMPLE

APIP!UCANT'~ NAME: -----

---------·-- - - - ---- ' a member of the Board of Managers I,

n;J prgsanting County, hereby certify that the application is in

order, propose the applicant for admission.

Date Manager Signature

rnooomsam8oommomoomooosoooooooo o oooooooooomoooo8omooooooooGoooooooeoooooooseoooooo

!RECOMMENDATIONS OF APPLICATION COMMITTEE

Date: - ----

We find the application is in order as of this date and recommend the admission of the applicant.

Signature- Chairman Application Committee 08888008008GG D D00 0 9000000 0 DOODOODOO D GOOO O Q00~000~0 8 8000D8mSD000 0 00~ 0 8 0 000 0 0 0 80D O Q

ORDER. OF ADMISSION

Date of Board Action: --- ------------The foregoing application is hereby approved and the formal admission is recommended by the

Board of Managers Executive Committee ___ ___ _ ___ _

All applications will be approved or disapproved at any regular or special meeting of the

Board of Managers or the Executive Committee and signed by at least six (6) members of the

Board of Managers.

Managers :

Register No.:------------- Book ____ Page ___ _

Approved: ______ _ Admitted: ______ _ Rejected : ______ _ 000800 0 008GO GOOO OQODOGOGOO D OGEDDB DB OO D OOQOODCDGGOOOIDOOOOOCOOO O ODOD O ODO D OCoooooooo

/For Use of' Home /Physician Only

MEDICAl CERTIFICATiON OF HOME PHYSICiAN

I have examined the within applicant and (DO) _ (DO NOT) _ recommend his admission .

Date: ------ ______ ____ ____ M.D. Signature - Home Physician

Comments/Remarks : _ _____________________________ _

15

Application for Admission Month Year

Revised. 07 2012

SAMPLE

ACKNOWLEDGEMENT OF RECEIPT OF GENERAL INFORMATION ABOUT

THE NEW JERSEY FIREMEN'S HOME

Please initial to the right of each of the line items below to signify that the information has been read and understood by the applicant and/or his representative:

Initials

1. Notice Of Monthly Assessment I Description of Charges

2. General Information on NJFH Operation

3. Responsibilities of NJFH Resident with Covered/Non-Covered

Charges

4. List of Suggested Clothing

5. NJFH Privacy Practices

Date: ---(Print Name)

WITNESS: (Print Name)

Application (or admission

16

(Signature)

(Signature)

Month Year Revised: 07 2012

SAMPLE

AUTIIENTICATION OF SIGNATURES IN ADMISSION APPLICATION

I, ___ _ ·----·--' certify the signatures placed on the pages

to this application herein are true and authentic. I am aware that if any part of this

representation is willfully false, I am subject to punishment as permitted by law.

Witness

Dated: -----

Revised 2016

Applicant's Signature or

Applicant's Representative

SAMPLE