30 DAY RESIDENTIAL BED HOLD EXTENSION REQUEST
For all bed hold requests beyond the standard 30 day residential bed hold period (see N.J.A.C 10:37A-11.4(c)below) , this form should be completed and sent to the DMHAS –Mental Health FFS Unit (see e-mail below) for review by the 20th day of the previous month for which the extension is being requested. The MH-FFS Unit will then forward the completed document to the appropriate DMHAS Program Analyst and Olmstead Coordinator (when applicable) for review.
COUNTY: AGENCY: DATE: Click here to enter a date.
NAME: DATE OF BIRTH:
DATE OF INITIAL INPATIENT HOSPITALIZATION, RESIDENTIAL ADDICTIONS TREATMENT OR RESIDENTIAL REHABILITATIVE CARE: Click here to enter a date.
NAME OF FACILITY WHERE THE CONSUMER INITIALLY RECEIVED, OR IS RECEIVING, INPATIENT HOSPITALIZATION, RESIDENTIAL ADDICTIONS TREATMENT OR RESIDENTIAL REHABILITATIVE CARE:
DATE OF TRANSFER TO EXTENDED TREATMENT UNIT (IF APPLICABLE): Click here to enter a date.
NAME OF FACILITY WHERE CONSUMER IS RECEIVING EXTENDED TREATMENT:
DOES THE TREATMENT TEAM HAVE A PROJECTED DISCHARGE DATE: YES ☐ NO ☐
PROJECTED DATE OF DISCHARGE: Click here to enter a date. (MUST BE WITHIN 45 DAYS FROM DATE OF REQUEST)
CLINICAL JUSTIFICATION FOR THE 30 DAY BED HOLD EXTENSION REQUEST (PLEASE PROVIDE DETAILED INFORMATION THAT THE RESIDENTIAL PROVIDER AND THE HOSPITAL, RESIDENTIAL ADDICTIONS OR RESIDENTIAL REHABILITATIVE CARE TREATMENT TEAM ARE IN AGREEMENT THE CONSUMER WILL BE ABLE TO RE-OCCUPY THE VACANT COMMUNITY BED WITHIN THE NEXT 30 TO 45 DAYS):
Email completed form to: including “BH Extension Request” in subject line.
AGENCY REPRESENTATIVE SIGNATURE:
DMHAS USE: