Daughters of Israel

Extra Charge And Explanation Form

Resident:
Date of Admission:
Unit/Room:

1.    Hospital bed holds:

a)    Medicare/Private pay residents must pay the private daily rate from the date of hospitalization if they choose to hold the resident’s bed;

b)    Medicaid residents will have their bed held for ten (10) days from the date of hospitalization.  After the tenth (10th) day, the responsible party may continue to hold the bed at the Medicaid rate, or the bed will be given up. 

c)    If the resident is in a private room at the family’s request, the additional $15.00 private room charge is applicable for bed holds.


Signature of Responsible Representative

Signature of Director of Admission’s

2.    Private room charge:

There is an additional charge of $15.00 per day for a private room.  This amount will be billed separately from your monthly bill and is payable with your monthly bill.   This charge is not a donation and should not be viewed as such.


Signature of Responsible Representative

Signature of Director of Admission’s

3.    Room Changes:

Daughters of Israel reserves the right to move residents from one room to another or from one unit to another based on medical needs and cognitive levels.  Responsible parties will be informed of the room/unit change, however the professional staff maintains sole discretion over room changes.


Signature of Responsible Representative

Signature of Director of Admission’s

4.    Monthly Income:

As a Medicaid recipient, the resident’s monthly income, including but not limited to social security, pension, and retiree benefits are payable to the facility by the third of every month.  By Medicaid law, these monies cannot be used to pay for any other expenses.  Non-payment of a resident’s monthly income will be considered Medicaid fraud and subject to investigation by the New Jersey Department of Health and Senior Services.


Signature of Responsible Representative

Signature of Director of Admission’s

 


Relationship to Resident

Date

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Phone: 973-731-5100 • Fax: 973-736-7698
www.doigc.org
1155 Pleasant Valley Way, West Orange, NJ, 07052
Copyright © 2012 Daughters of Israel