D.7 REQUEST FOR EXTENSION OF PER DIEM FORM.pdf
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- Solicitation number
- 36C24226R0065
About this file
This document is a D.7 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.
Part I of the form is completed by the contractor and submitted to the HCHV Coordinator/VA Liaison when a request for per diem extension beyond the standard 180-day period is needed. Required contractor submissions include the veteran's name, Social Security number, facility name, contract number, admission date, the 180th day date, detailed reasons for the extension request, the veteran's housing plan and expected departure date, and the contractor representative's signature. Part II is completed by the VA HCHV Coordinator/VA Liaison and evaluates four specific criteria: whether extenuating clinical circumstances exist beyond the housing placement, whether the contractor has documented exhaustive housing placement efforts, whether the VA Liaison was appropriately advised in advance of the 180-day limit, and whether the veteran will continue to derive therapeutic benefits from continued facility stay. The VA Liaison provides recommendations to the Contracting Officer's Technical Representative (COTR), who makes the final determination on whether to grant per diem continuation and specifies the extension end date and date for next review. All negative responses require documentation in the comments section.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24226R0065 0002.docx | DOCX document | |
| 36C24226R0065 0001.docx | DOCX document | |
| D.8 WAGE DETERMINATION.pdf | ||
| D.2 INFORMATION SECURITY RULES OF BEHAVIOR.docx | DOCX document | |
| 36C24226R0065.docx | DOCX document | |
| D.5 HCHV INSPECTION FORM.pdf | ||
| D.6 INCIDENT REPORT FORM.pdf | ||
| D.1 QASP - Northport VA HCHV 2026.docx | DOCX document | |
| D.3 PAST PERFORMANCE REFERENCE INFORMATION.docx | DOCX document | |
| D.4 KEY PERSONNEL.docx | DOCX document |
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Text version
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:
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 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 COTR that per diem payments continue after the 180th day from the date of admission?
Yes No
VA Liaison Signature & Date: _______________________________________________________________
Does the COTR grant permission for the continuation of per diem?
Yes No
If yes, until what date? ______________________________
Date of next review: ________________________________________________________________________
COTR Signature & Date: ___________________________________________________________________
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