New Jersey Department of Human Services (DHS)

Division of Aging Services (DoAS)

PACE Administration

PO Box 807

Trenton, NJ 08625-0807

PACE Request for Deemed Continued Eligibility

To request that a participant have Deemed Continued Eligibility for PACE, complete the information below and submit all required documentation listed on this form to DHS, DoAS, at least 45 days prior to the last annual recertification authorization date.

From (Name/Title):
PACE Organization:
Email Address:
Telephone Number:	Fax Number:
Date of Request:	Recertification Due Date:
Participant Name:	Date of Last Assessment:
DoAS will only initiate the review of this request when all of the following documentation has been received. Omitting any information requested below will delay approval and jeopardize a participant’s eligibility for continued enrollment in PACE.

Justification summary from IDT

Initial and updated LOC assessment

Diagnosis of chronic or disabling condition

Last comprehensive assessment by all relevant disciplines

Last 2 IDT care plans

History and Physical

Physician and nursing progress notes

All specialty consultant notes (any discipline)

Social work notes

Diagnostic tests supporting request

Medication and treatment record

Other relevant documentation supporting the request

Above request is:
Authorized/Date:	Not Authorized/Date:
Name and Title of Reviewer:
Signature:
Date:	Telephone:

CP-3

MAR 18

CP-3, PACE Request for Deeming of Continued Eligibility

CP-3, PACE, Request for Deeming of Continued Eligibility, nursing facility,

Windows User

2018-03-13

human services