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

Current through Register Vol. 56, No. 14, July 15, 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