N.J. Admin. Code § Tit. 10, ch. 49, app APPENDIX
Current through Register Vol. 56, No. 21, November 4, 2024
| Health Benefits Identification (HBID) Card | Form #1 |
| HBID Emergency Services Letter | Form #1A |
| Medically Needy Claim Transmittal (FD-311) | Form #2 |
| Public Assistance Inquiry (PA-1C) | Form #3 |
| One Page NJ FamilyCare Presumptive Eligibility | Form #4 |
| Application | |
| One-Page NJ FamilyCare Application | Form #5 |
| Retroactive Eligibility Application | Form #6 |
| Validation of Eligibility (FD-34) | Form #7 |
| Provider Application (FD-20) | Form #8 |
| One Time Enrollment Application (FD-20A) | Form #8A |
| Provider Agreement (FD-62) | Form #9 |
| Disclosure of Ownership and Control Interest | Form #10 |
| Statement (CMS-1513) | |
| Patient Certification Form (FD-197) | Form #11 |
| Notice to All Applicants and Providers | Form #12 |
| Medical Assistance Customer Centers Directory | Form #13 |
| New Jersey County Welfare Agencies | Form #14 |
N.J. Admin. Code Tit. 10, ch. 49, app APPENDIX
See: 29 N.J.R. 2512(a), 29 N.J.R. 3856(a).
Repealed Forms 7, 15 and 16, and recodified Forms 8 through 14, and 17, as Forms 7 through 13, and 14, respectively; and added Form 158.
Amended by R.2003 d.82, effective 2/18/2003.
See: 34 N.J.R. 2650(a), 35 N.J.R. 1118(a).
Amended by R.2006 d.25, effective 1/17/2006.
See: 37 N.J.R. 3176(a), 38 N.J.R. 802(a).
In Form 10, replaced (HCFA-1513) forms with (CMS-1513) forms.
Amended by R.2008 d.230, effective 8/4/2008.
See: 40 N.J.R. 984(a), 40 N.J.R. 4531(a).
Updated the list of forms at the beginning of the appendix; repealed former Forms 1, 4, 5, 6, 8, 9 and 14 and adopted each as new rules;
adopted Forms 1A, 8A and 13 as new rules; amended Form #3 to relocate the designation "Form #3" to the final page; amended Form #10 to include the designation "Form #10" on the final page; and repealed Form 15.