D.8 REQUEST FOR EXTENSION OF PER DIEM.pdf
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- Solicitation number
- 36C24226Q0118
About this file
This is a template form for requesting extensions of per diem payments for veterans in contract residential care under the VA New York/New Jersey Health Care Network's Health Care for Homeless Veterans (HCHV) program, associated with RFQ 36C24226Q0118.
Part I of the form is completed by the contractor and requires documentation of the veteran's identifying information (name, Social Security number, facility name, contract number, and admission date), the specific reason(s) for requesting the per diem extension beyond the standard 180-day limit, and the veteran's housing plan with expected departure date. The contractor representative must sign and date the request and submit it to the HCHV Coordinator/VA Liaison as soon as the need for extension becomes known. Part II is completed by the VA HCHV Coordinator/VA Liaison and requires evaluation of four specific criteria: whether extenuating clinical circumstances beyond the contractor's control exist as barriers to housing placement; whether documented evidence shows the contractor has exhausted all efforts to place the veteran in housing sooner; whether the VA Liaison has been appropriately advised of these efforts well in advance of the 180-day limit; and whether the VA Liaison concurs that the veteran will continue to derive therapeutic benefits from continued stay at the facility. The VA Liaison must then recommend approval or denial to the Contracting Officer's Technical Representative (COTR), who makes the final determination on whether to grant per diem continuation and establishes the extension end date and next review date.
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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 180 th 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: _________________________________________________________________________
ATTACHMENT D.8- REQUEST FOR EXTENSION OF PER DIEM RFQ 36C24226Q0118
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 COTR that per diem payments continue after the 180 th 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: ___________________________________________________________________
ATTACHMENT D.8- REQUEST FOR EXTENSION OF PER DIEM RFQ 36C24226Q0118
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