36C26220R0041-019.pdf

ATTACHMENT F: Request for Extension of Per Diem Form

This form will be used by all Contractors to request extension of per diem payments when a Veteran’s length of stay will exceed 180 days from the date of admission. Please refer to Section II, subsection

“Admissions, Length of Stay and Discharges” for specific criteria for using this form.

Extensions request protocol:

Date:

Current Stay Expires:

Extension Approved Until:

Extensions of the Veteran initial authorized period shall be requested in writing by the Contractor, with justification of the Veteran’s need and updated treatment plan. Approvals shall be authorized in writing by the VA Grant and Per Diem Program Manager/Contracting Officer Representative (COR).

Please complete the following and provide to the program liaison for review.

1. Justification of Veteran’s need for extension:

2. Steps taken to date to house veteran:

3. Barriers identified:

4. Plan to mitigate barriers:

5. Plan to be implemented during extension period: (please include timeline)

6. Housing plan: (please give a minimum of 2 housing plans)

7. Is veteran in agreement with plan?

Please attach: Updated treatment plan

Please note: Case will be reviewed in incremental time frames while in extension period.