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4-25-02 letterhead - State of New Jersey - nj 2026
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- Click ‘Get Form’ to open the 4-25-02 letterhead in the editor.
- Begin by entering the Nursing Facility name at the top of the form. This identifies where the PEME request is originating from.
- Fill in the Resident Name and Medicaid case number. Ensure accuracy as this information is crucial for processing.
- Input the Medicaid Eligibility Approval Effective Date, which marks when eligibility begins.
- For each month requested (up to three), provide Dates of Service, Medicaid daily rate for room and board, and total reimbursements received from other insurance.
- Calculate and enter the Total room and board amount requested using the formula provided on the form. Repeat for each month.
- Complete any additional charges if applicable, ensuring all documentation is attached for verification.
- Finally, have the Nursing Facility Representative sign and date at the bottom of the form before submission.
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