New Jersey Administrative Code › Title 8 - HEALTH › Chapter 133 - INTERIM ASSISTANCE PROCEDURES MANUAL › Appendix B

Current through Register Vol. 56, No. 14, July 15, 2024
APPENDIX B
NEW JERSEY DEPARTMENT OF HUMAN
						SERVICES
DIVISION OF MENTAL HEALTH SERVICES
AUTHORIZATION FOR REIMBURSEMENT OF INITIAL
						SUPPLEMENTAL SECURITY INCOME (SSI)
PAYMENT OR INITIAL SSI POSTELIGIBILITY
						PAYMENT (MH-30) COMMUNITY PLACEMENTS
GR Code ___________________
________________________________________________
___________________________
(Applicant's Name)
(Social Security Number)
________________________________________________
___________________________
(Mailing Address)
(Hospital)
I understand and authorize that:
For Interim Assistance to be granted to me, and upon
						the approval for SSI
Benefits, the Social Security Administration will
						forward to the above
hospital my (check one):
______
Initial SSI payment
______
Initial SSI posteligibility payment
I further authorize said Business Manager to deduct
						from my (check one):
______
Initial SSI payment as reimbursement an amount equal
						to the total amount of Interim Assistance which I received from this hospital (not
						including assistance payments financed wholly or partially with Federal funds) from
						the date I became eligible for benefits through the month in which my SSI benefits
						begin.
______
Initial posteligibility payment as reimbursement an
						amount equal to the total amount of Interim Assistance I received from this hospital
						(not including assistance payments financed wholly or partially with Federal funds)
						from the date my SSI benefits are subsequently reinstated after a period of suspense
						or termination and ending with and including the month my SSI benefits resume.
However, if the hospital has prepared and cannot
						stop delivery of its last assistance payment when it receives my retroactive SSI
						benefit payment from the Social Security Administration, that payment is included as
						Interim Assistance to be reimbursed.
I understand that the hospital will pay Interim
						Assistance funding for the entire month in the beginning of each month; if residency
						is terminated, I must notify the hospital of the plan to terminate as soon as
						possible, but no later than the day following termination; and I must notify the
						hospital of my new living arrangements in order for funds to be distributed to me or
						my representative payee from the SSI retroactive check received by the hospital
						after the hospital recovers Interim Assistance paid on my behalf.
I understand that the payment to me or my
						representative payee and a written explanation showing how the balance was
						calculated will be made within five working days after the Business Manager receives
						the SSI check.
I understand that an Interim Assistance Payee is not
						entitled to receive dual payments for care provided. I also understand that I, as
						the client, or another 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 of Interim
						Assistance payments received after the first SSI or other payment is received if
						such payment represents duplicate compensation; and (3) refund the hospital the
						amount of Interim Assistance from the retroactive SSI payment, which represents a
						duplicate payment to me for the time period from SSI application to receipt of
						funds.
I further understand that if I disagree with the
						amount of the deduction made by the Business Manager, I have the right to an
						administrative review by the NJ Division of Mental Health Services. I must make the
						request for a review through the Department of Human Services, Division of Mental
						Health Services, PO Box 727, Trenton, NJ 08625.
I understand that this signed authorization is
						effective for (1) one year from the date it is received by the above Agency and it
						will cease to have effect at the end of one year unless:
~ I understand that this signed authorization is
						effective for (1) one year from the date it is received by the above Agency and it
						will cease to have effect at the end of one year unless:
~ I appeal my suspension or termination on or before
						that time, or my SSI case is completely decided, or the above Agency and I mutually
						agree to terminate this authorization
In addition, I understand that signing this
						authorization form means I want to file for SSI benefits. I also understand that I
						must file an SSI application with a Social Security office for the Social Security
						Administration to decide if I am eligible for SSI benefits. I understand that if I
						am found eligible for SSI benefits that my eligibility for SSI can begin as early as
						the date the Hospital receives this signed authorization, but only if I file the SSI
						application within 60 days from the date the above agency receives this signed
						authorization.
Date: ___________________
Signed: _______________________________________
Address: ______________________________________
Form MH-30 (Revised 11/05)