N.J. Admin. Code § Tit. 8, ch. 133, app D
STATEMENT OF BUSINESS MANAGER STATE PSYCHIATRIC HOSPITAL
| ...................................... | ...................................... |
| (Hospital) | (Client Name) |
| ...................................... | ...................................... |
| (Business Manager) | (Client Social Security Number) |
As Business Manager of the above-named State Psychiatric Hospital, I agree to authorize commitment of funds for Interim Assistance to, or on behalf of, the stated client. The client must be a bona fide SSI applicant for those goods and services required during the period while the application for SSI is being investigated.
The original copy of this completed form will be sent to the local Social Security Administration (SSA) District Office. One copy will go to the Discharge/Financial Coordinator or equivalent at the above noted hospital.
If an SSI check is received from the SSA on behalf of the applicant (client), I will arrange to deposit it into the client's patient trust account. I will arrange to pay to the hospitals Interim Assistance account an amount equal to the total recoverable assistance granted during this period. The hospital will pay to the applicant or representative payee the balance, if any, within five (5) business days from the date of receipt of the check by the above hospital. The payment will be accompanied by a completed copy of Form FS-9, explaining how the hospital computed the amount.
All accounts and records dealing with this activity shall be available for examination by duly authorized State and/or Federal representatives.
Under the Interim Assistance Placement procedure funded through the Division of Mental Health Services, recipients first check should go to the above hospital.
| ......................... | ................................................... |
| (Date) | (Signature of Business Manager) |
Distribution:
SSA/DO--Original
Business Manager
Discharge/Financial Coordinator
Form FS-10 (Revised 7/95)
N.J. Admin. Code Tit. 8, ch. 133, app D