Form Jacc 405 - Application For Jersey Assistance For Community Caregiving (Jacc) (Page 3 of 4) in pdf

Form Jacc 405 - Application For Jersey Assistance For Community Caregiving (Jacc) Page 3

THE FOLLOWING CERTIFICATION AND AUTHORIZATION MUST BE SIGNED.

I/WE CERTIFY THAT THE INFORMATION ABOVE IS TRUE AND ACCURATE.

I/WE WILL NOTIFY J ACC IMMEDIATELY OF THE FOLLOWING: ANY INCOME OR RESOURCE INCREASE ABOVE LEGAL LIMITS;

A MOVE FROM NEW JERSEY; IF MEDICAID ELIGIBLE: IF DISABILITY BENEFITS FROM THE SOCIAL SECURITY

ADMINISTRATION (SSA) ARE HALTED; OR THE NATURE OF THE DISABILITY CHANGES.

I/WE UNDERSTAND THAT A VISIT BY REPRESENTATIVES OF JACC MAY OCCUR IN ORDER TO VERIFY ELIGIBILITY AND TO

DETERMINE AVAILABILITY OF OTHER HOME CARE COVERAGE AND THAT SUCH VISITS ARE ACCEPTABLE.

I/WE AUTHORIZE THE RELEASE OF INFORMATION NECESSARY TO DETERMINE J ACC ELIGIBILITY FROM THE RECORDS IN

POSSESSION OF THE SSA, INTERNAL REVENUE SERVICE AND THE NEW JERSEY DIVISION OF TAXATION, EMPLOYER,

BANKS, AND OTHERS AS THE NEED ARISES.

I/WE ARE AWARE THAT THIS IS A CO-PAY PROGRAM AND NON-PAYMENT SHALL RESUL TIN DISENROLLMENT FROM THE

PROGRAM. I/WE ARE AWARE THAT IF MY/OUR Co-PAY COUNTABLE INCOME EXCEEDS 365% OF THE FEDERAL POVERTY

LEVEL, THE, I/WE WILL BE DISENROLLED FROM THE PROGRAM. I/WE UNDERSTAND THAT CO-PAY COLLECTION WILL NOT

BEGIN UNITL THE MONTH FOLLOWING FINAL DETERMINATION OF ELIGIBILITY.

I/WE REQUEST TO BE DETERMINED PRESUMPTIVELY ELIGIBLE FOR J ACC:.

YES

- -

I/WE UNDERSTAND THIS MEANS THAT I/WE WILL RECEIVE. BENEFITS PENDING A FINAL DETERMINATION OF ELIGIBILITY.

I/WE UNDERSTAND THAT A FINAL DETERMINATION WILL BE MADE UPON SUBMISSION OF ANY DOCUMENTATION

REQUIRED AS NOTED ON PAGE 4 OF THIS APPLICATION. I AGREE TO SUPPLY THE DOCUMENTATION WITHIN 14 DAYS OF

THIS APPLICATION DATE. BASED ON ITS FORMAL REVIEW, THE DHSS MAY REQUIRE ADDITIONAL INFORMATION OR

DOCUMENTATION, AND I/WE AGREE TO SUPPLY ANY ADDITIONAL REQUESTED INFORMATION WITHIN THE TIMEFRAMES

REQUIRED. I/ WE UNDERSTAND THAT IF ANY REQUIRED DOCUMENTATION IS NOT SUPPLIED WITHIN THE REQUIRED TIME

FRAME, THE APPLICATION WILL BE AUTOMATICALLY WITHDRAWN AND BENEFITS DISCONTINUED. IF FOUND INELIGIBLE,

I/WE UNDERSTAND THAT BENEFITS RECEIVED IN THE J ACC PROGRAM WILL BE DISCONTINUED AND I/WE WILL BE

DISENROLLED FROM THE PROGRAM. I/WE AGREE TO BE BOUND BY THE TERMS OF THE PARTICIPANT ENROLLMENT

AGREEMENT DURING THE PRESUMPTIVE ELIGIBILITY PERIOD AND IF FOUND ELIGIBLE, THROUGHOUT THE DURATION OF

ENROLLMENT IN THE PROGRAM.

SIGNATURE OF APPLICANT

DATE

SIGNATURE OF SPOUSE

DATE

APPLICANT TELEPHONE

(

)

SIGNATURE OF PREPARER

Telephone (

)

PERSON TO CONTACT FOR QUESTIONS

Telephone (

)

J ACC 405 (REV.B/00)

Form Jacc 405 - Application For Jersey Assistance For Community Caregiving (Jacc) Page 3