36C24218R0338-006.pdf

HCHV Contract Residential Care Statement of Work

VA New York / New Jersey Health Care Network Health Care for Homeless Veterans (HCHV)

Contract Residential Care

Request for Extension of Per Diem

Part I: To be completed by the Contractor and faxed to the HCHV Coordinator/ VA Liaison as soon as the need for the request is known.

Date:

Name of Veteran: Social Security No:

Agency / Facility:

Contract No:

Date Veteran admitted to the program:

Date of 180th day in contract residential care from date of admission:

Reason(s) for request for extension of per diem:

What is the Veteran’s housing plan and expected date of departure from HCHV Contract Residential Care?

Contractor Representative completing this request:

Name: Title:

Signature: Date:

HCHV Contract Residential Care – Request for Extension of Per Diem

Part II: To be completed by the VA HCHV Coordinator/VA Liaison

Date Received by VA HCHV Coordinator/VA Liaison: ___________________________________________

Have the following criteria been met?

(Check all that apply) Yes No Comments

1. There are extenuating clinical circumstances beyond the contractor’s control that are barriers to the Veteran’s placement in housing.

2. There is documented evidence that the contractor has exhausted every effort to place the Veteran in housing sooner.

3. The VA Liaison has been appropriately advised of these efforts well in advance of the 180 day limit.

4. The VA Liaison concurs that the Veteran will continue to derive therapeutic benefits from a continued stay at the HCHV Contracted Residential Care facility.

*Comments section should be completed for all negative responses.* Does the HCHV Coordinator/VA Liaison concur with the reasons for the request?

� Yes � No

Does the HCHV Coordinator/VA Liaison recommend to the COR that per diem payments continue after the 180th day from the date of admission?

Yes No

VA Liaison Signature & Date: _______________________________________________________________

Does the COR grant permission for the continuation of per diem?

Yes No

If yes, until what date?

Date of next review:

COR Signature & Date: ___________________________________________________________________