N.J. Admin. Code § Tit. 8, ch. 133 app K
Current through Register Vol. 56, No. 9, May 6, 2024
| APPENDIX K | |
| HEALTH BENEFITS IDENTIFICATION CARD | |
| Emergency Services Letter |
| Dear Provider: (Please see checked block below) | |
| [ ] NEW APPLICANT: The NJ FamilyCare/Medicaid client listed below has been newly approved as eligible, and will receive a permanent plastic Health Benefits Identification (HBID) card in the mail shortly. In the meantime, please accept this letter in place of the client's new permanent HBID card. For new applicants only this letter serves as temporary verification of Medicaid eligibility for the period listed below. | |
| [ ] CLIENT AWAITING REPLACEMENT CARD: The NJ FamilyCare/Medicaid client listed below is awaiting a replacement card. In the interim, please use the Medicaid information for the client, printed below, in order to determine eligibility for this client using any one of the available eligibility verification systems you normally use. This letter is not proof of eligibility for this client. | |
| CLIENT | |
| Medicaid ID ................................................................ | |
| Client Name ................................................................ | |
| Date of Birth .............................................................. | |
| HMO Plan & Service Package ................................................. | |
| TPL & Medicare Coverage ................................................... | |
| Pharmacy Restrictions ...................................................... | |
| Client Address ............................................................. | |
| AUTHORIZING OFFICE | |
| Office Name ................................................................ | |
| Name of Staff Contact ...................................................... | |
| Phone Number ............................................................... | |
| EMERGENCY SERVICES LETTER VALID FROM ________ UNTIL ________ | |
| FD-412 (05/23/06) |
N.J. Admin. Code Tit. 8, ch. 133 app K