New Jersey Department of Human Services

Division of Aging Services

Office of Long Term Services and Supports

Quality Management	CLIENT TRACKING FORM
To:	Date:
Care Management Provider OR

DHS Regional Office of Community Choice Options (OCCO)
From:	Phone:
Assisted Living/Adult Family Care (AL/AFC) Provider OR

Care Management Provider
MLTSS PARTICIPANT INFORMATION
Participant Name

Participant Medicaid Number

Pending	Social Security Number

Relative/Contact Name

Daytime Phone Number

AL/AFC PROVIDER INFORMATION N/A
Provider Name

Provider Medicaid Number

Provider Street Address, City, State, Zip Code

Provider Contact Person

Provider Phone Number

ACTION TO NOTE
For Use by AL/AFC Providers (Check one):
Admission Date to AL/AFC:
Participant has entered a hospital, nursing facility (NF) or sub-acute rehab:
Date:
Destination:
Phone:
Readmission Date to AL/AFC:
Permanent Discharge/Transfer from AL/AFC Facility:
Date:
Destination:
Phone:
Reason:
Non-medical Leave from AL/AFC (> 14 days):
Request for Pre-Admission Screening (PAS)
Date of Death:
For Use by Care Management Sites:
Request for Pre-Admission Screening (PAS)
Completed By (Print Name)

Title

Signature

Date

ACS-13

MAR 16

ACS-13, Client Tracking Form

ACS-13, Client tracking form, assisted living, adult family care, ACS, aging and community services

Windows User

2016-03-08

aging