D.5 REQUEST FOR EXTENSION OF PER DIEM FORM.pdf

This is a Request for Extension of Per Diem form used by the VA New York/New Jersey Health Care Network's Health Care for Homeless Veterans (HCHV) program for contract residential care services.

Part I of the form is completed by contractors and submitted to the HCHV Coordinator/VA Liaison when extension of per diem payments beyond the standard 180-day period is required. Contractors must provide veteran information including name, Social Security number, facility details, contract number, admission date, and the 180th day marker. The form requires contractors to document reasons for the extension request and describe the veteran's housing plan and expected departure date from HCHV contracted residential care. Part II is completed by the VA HCHV Coordinator/VA Liaison and evaluates whether four criteria are met: (1) extenuating clinical circumstances beyond contractor control exist as barriers to housing placement; (2) the contractor has exhausted all efforts to place the veteran in housing; (3) the VA Liaison was appropriately advised of these efforts in advance of the 180-day limit; and (4) the VA Liaison concurs that continued stay will provide therapeutic benefit. The VA Liaison must recommend to the Contracting Officer (COTR) whether per diem payments should continue. The COTR makes the final determination on permission for continuation, specifying the authorization date if approved, and schedules the next review date. This form facilitates the administrative and clinical review process for residential care extensions beyond the standard contract term.