N.J. Admin. Code § Tit. 8, ch. 133, app B
Current through Register Vol. 56, No. 11, June 3, 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)
N.J. Admin. Code Tit. 8, ch. 133, app B