DDD-Application for Determination of Eligibility(V5)

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Application for Determination of Eligibility (V5)
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Pre-Application

Answer a few questions to help us tailor the application to your situation. This will streamline the process by skipping sections that don't apply.

Based on your response, you may NOT need to upload Medical Documentation of Disability. DDD will attempt to obtain prior records from DDD archives and/or Perform Care. You may optionally upload available supporting documents to help speed up processing. DDD will contact you if additional information is needed.  

To make the application filing process faster, please scan and save all required documents in a single folder on your computer or laptop before you begin. 

Please gather the documents listed below before proceeding with the application.

 What You Will Need

Documentation of Age, Citizenship, Residency  

  • Birth Certificate 
  • Social Security Card or Proof of Citizenship or Green Card 
  • One Residency Document: 
    • NJ MVC Photo ID 
    • DMV ID, Pay Stub, W-2, Tax Bill, Etc.

Documentation of Guardianship or Power of Attorney (if applicable)

  • Guardianship Order or Power of Attorney 
  • Guardian's Address Documents: DMV ID, Pay Stub, W-2, Tax Bill, Etc. 

Documentation of Medicaid Eligibility 
Provide One: 

  • SSI Annual Award Letter 
  • SSDI Annual Award Letter 
  • Medicaid ID Card / Medicaid Approval Letter 
  • PerformCare ID, Name, Address, Phone Number (If Applicable) 

Documentation of Developmental Disability
Helpful but not required: 

  • Medical Documentation of Disability
  • Psychological Evaluations (with IQ scores) 
  • Speech/OT/PT Evaluations 
  • Neurological Evaluations 
  • Psychiatric Evaluations 
  • Child Study Team Reports 
  • Hospital Records 
  • DVRS Assessments 
  • Social Summaries 
  • Most Recent IEP  
  • All available psychological reports 

Other Documents (if applicable)

  • DVRS Records/Evaluations (F3 or F6 Form) 
  •   Employment/Day Services Document(s) * 

 

 


Please refer to the User Guide for instructions on completing the application. 

If you have questions or comments about the application, please contact us by email at DDD.BeforeYouApply@dhs.nj.gov or through the Contact Us form.

To determine whether you have already applied for and may be eligible for services through the NJ Children’s System of Care, call PerformCare at 877-652-7624.

To determine whether you have already applied for and may be eligible for DDD services, call DDD Intake at 800-832-9173. When prompted, press 2, then select your county.

To make the application filing process faster, please scan and save all required documents in a single folder on your computer or laptop before you begin.

Please gather the documents listed below before proceeding with the application.

 What You Will Need

Documentation of Age, Citizenship, Residency  

  • Birth Certificate 
  • Social Security Card or Proof of Citizenship or Green Card 
  • One Residency Document: 
    • NJ MVC Photo ID 
    • DMV ID, Pay Stub, W-2, Tax Bill, Etc.

Documentation of Guardianship or Power of Attorney (if applicable)

  • Guardianship Order or Power of Attorney 
  • Guardian's Address Documents: DMV ID, Pay Stub, W-2, Tax Bill, Etc. 

Documentation of Medicaid Eligibility 
Provide One: 

  • SSI Annual Award Letter 
  • SSDI Annual Award Letter 
  • Medicaid ID Card / Medicaid Approval Letter 
  • PerformCare ID, Name, Address, Phone Number (If Applicable) 

Documentation of Developmental Disability
Required: 

  • Medical Documentation of Disability 
Helpful but not required: 
  • Psychological Evaluations (with IQ scores) 
  • Speech/OT/PT Evaluations 
  • Neurological Evaluations 
  • Psychiatric Evaluations 
  • Child Study Team Reports 
  • Hospital Records 
  • DVRS Assessments 
  • Social Summaries 
  • Most Recent IEP  
  • All available psychological reports 

Other Documents (if applicable)

  • DVRS Records/Evaluations (F3 or F6 Form) 
  •   Employment/Day Services Document(s) * 

 

 


Please refer to the User Guide for instructions on completing the application. 

If you have questions or comments about the application, please contact us by email at DDD.BeforeYouApply@dhs.nj.gov or through the Contact Us form.

To determine whether you have already applied for and may be eligible for services through the NJ Children’s System of Care, call PerformCare at 877-652-7624.

To determine whether you have already applied for and may be eligible for DDD services, call DDD Intake at 800-832-9173. When prompted, press 2, then select your county.

The applicant (person in need of services) must be aged 18 or older to apply for a determination of eligibility for services through DDD.

 

For applicants under age 18, an application for determination of eligibility must be submitted through the NJ Children's System of Care, or PerformCare. For information or to apply, visit PerformCare or call 877-652-7624.

Application for Determination of Eligibility (V5)

Use these links for help completing your application: Application Checklist, User Guide or Email: DDD.NJApply@dhs.nj.gov 

Section A: Application

Please fill in the Applicant details below.
Preferred Contact Method (Check all that apply)

Section B: Applicant U.S. Citizenship & NJ Residency

Applicant must demonstrate that NJ is their primary residence to apply for services through NJ DDD.

Section C: Applicant School, Employment, & Other Services

Click here to learn more about the New Jersey State minimum wage information

Section D: Applicant Medicaid & Social Security

(To receive services through DDD, Applicant must obtain Medicaid. If Applicant has difficulty obtaining Medicaid, contact  DDD’s Medicaid Eligibility Helpdesk: DDD.MediEligHelpdesk@dhs.nj.gov)
Are these payments from (Check all that apply)
5. Do you have any other insurance? (Check all that apply)

Section E: Applicant Household Member(s)

Section F: Supporting Documentation

Documentation of Developmental Disability.
Application for Determination of Eligibility (V5)

Use these links for help completing your application: Application Checklist, User Guide or Email: DDD.NJApply@dhs.nj.gov 

Section G: Participant Enrollment Agreement

DDD 1115 NJ FamilyCare COMPREHENSIVE DEMONSTRATION

PARTICIPANT ENROLLMENT AGREEMENT

 

By signing this Participant Enrollment Agreement, the Participant, Guardian (as applicable), and Family (as applicable) accept and agree to the following terms and conditions of the Supports or Community Care Program:

  1. The provisions herein shall apply to participation in the Program as operated by the NJ Division of Developmental Disabilities (DDD) and approved by the federal Centers for Medicare and Medicaid Services (CMS).
  2. Participant understands that accessing services from the DDD is voluntary and that he/she may utilize any willing service provider who meets the State’s Provider Qualifications and has been identified in the Individualized Service Plan (ISP), subject to the terms of #4 of this document.
  3. Participant shall comply with all policies and procedures established by the State governing participation in the program as outlined in the applicable Program Policies and Procedures Manual.
  4. Participant may receive the types of services required to meet his/her assessed needs at the rates set forth in and prior authorized by the approved Individualized Service Plan (ISP).
  5. Approved providers/self-directed employees (SDE) will be paid for all prior authorized services rendered, on behalf of Participant and as authorized in the ISP. The Participant shall not receive any direct payments.
  6. The State may dis-enroll a Participant from the program and/or discontinue all payment, as applicable, to a provider/SDE, if one or more of the following circumstances occur:

    (a) The Participant has not provided all information and documents required;

    (b) The Support Coordinator or the State has reasonable cause to believe that the Participant has been or is engaged in willful misrepresentation, exploitation, fraud or abuse related to the provision of services under this Participant Enrollment Agreement;

    (c) The Participant consistently seeks payment for unauthorized or inappropriate charges;

    (d) The Participant refuses to allow, or does not participate in, monthly, quarterly, and annual contacts/visits conducted by the Support Coordinator in accordance with guidelines provided in the applicable Policies & Procedures Manual;

    (e) The Participant fails to submit on a timely basis documents and records required in relation to the provision of services under this Participant Enrollment Agreement;

    (f) The Participant fails to report changes in care needs and financial circumstances that may affect eligibility;

    (g) The Participant is no longer Medicaid eligible;

    (h) The Participant has moved out of the State;

    (i) The Participant no longer meets the required Level of Care;

    (j) The Participant has enrolled in another HCBS or MLTSS program;

    (k) The Participant has failed to abide by any terms of this Participant Enrollment Agreement;

    (l) The Participant chooses to no longer receive services from the Division/Program; or

    (m) The Participant is not accessing Program services other than Support Coordination for greater than 90 days.

     In the event of disenrollment or discontinuation of payment, the Participant shall be solely liable for the cost of all services received after notification from the State pursuant to #7 of this document.   

  7. The State shall provide 30 days notice to the Participant in the event of dis-enrollment or discontinuation of payment pursuant to 6(a), 6(d), or 6(e) above. During this 30 day time period, the Support Coordinator and Division will provide assistance and support as needed to help the individual in addressing the issue(s) for which he/she is being dis-enrolled. If the issue(s) has been addressed within those 30 days, his/her waiver status will be reinstated.
  8. Individuals subject to removal from the Program are entitled to the opportunity to request a Fair Hearing. The Participant must request a Fair Hearing within 20 days of the date of notification of dis-enrollment.
  9. If the Participant finds the provider or SDE to be unsatisfactory or suspects misrepresentation; fraud; abuse; or violation of the law in rendering services, the Participant should terminate the relationship and must report the termination and reasons therefore to the Support Coordinator. The Participant must report to the Support Coordinator or the State any suspected exploitation, misrepresentation, fraud, or abuse related to the provision of services under this Participant Enrollment Agreement.
  10. Participant shall provide to the State or agent/representative of the State all documents and records related to participation in the program, on a timely basis. The State or agent/representative of the State shall also be allowed access to all such documents and records for audit purposes.
  11. Participant is subject to all applicable statutes, regulations, and laws governing non-discrimination.
  12. Participant attests that at the time of application/enrollment onto the Program no transfers of assets were made during the look back period per Section 1902 (a)(18) insofar incorporates Section 1917(c).
  13. The Program maintains provisions for the Participant to exercise choice and control in managing Waiver services and other supports in accordance with their needs and personal preferences.
  14. This Participant Enrollment Agreement is effective as of the date last signed and shall remain in full force and effect until such time as Participant is no longer enrolled in the Program.      

NJ Division of Developmental Disabilities November 2017

Section H: (Form A) Acknowledgement of Receipt of Notice of Privacy Practices

NOTICE OF PRIVACY PRACTICES

Effective Date:  October 15, 2018

This Notice applies to individuals receiving services from the Department of Human Services’ (DHS) Division of Developmental Disabilities and does not require your response. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

YOUR RIGHTS

  • Right to see and copy your records. In most cases, you have a right to view or get copies of your records. You must make your request in writing. We will provide a response to your request within thirty (30) days. You may be charged a fee for the cost of copying your records.
  • Right to an electronic copy of your medical records. If your information is maintained in an electronic format, you may request that your electronic records be transmitted to you or another individual or entity. We will respond to your request within thirty (30) days.
  • Right to correct or update your records. You may ask us to correct your health information if you think there is a mistake. You must make your request in writing and provide a reason for your need to correct the information.
  • Right to choose how we communicate with you. You may ask us to share information with you in a certain way. For example, you can ask us to send information to your work address instead of your home address. You must make this request in writing. You don’t have to explain a reason for the request. We may deny unreasonable requests.
  • Right to get a list of disclosures. You have a right to ask us for a list of disclosures made after April 14, 2003. You must make a request in writing. This will not include information shared for treatment, payment or health operation purposes. We will provide one accounting a year free of charge, but may charge a cost for additional lists provided within the 12-month period.
  • Right to get notice of a breach. You have a right to be notified upon a breach of any of your protected health information.
  • Right to request restrictions on uses or disclosures. You have a right to ask us to limit how your information is used or shared with others. You must make the request in writing and indicate what information should be limited. We are not required to agree to a requested restriction. If you paid out-of-pocket expenses in full for a specific item or service, you have a right to ask that your information with respect to that item or service not be disclosed. We will always honor that request.
  • Right to revoke authorization. If we ask you to sign an authorization to use or disclose your information, you can cancel that authorization at any time. You must make that request in writing. Your request will not affect information that has already been shared.
  • Right to get a copy of this notice. You have a right to ask for a paper copy of this notice at any time.
  • Right to file a complaint. You have a right to file a complaint if you don’t agree with how we have used or disclosed your information.
  • Right to choose someone to act for you. If someone has been legally designated as your personal representative, that person can exercise your rights and make choices about your health.

OUR DUTIES

The Department of Human Services functions as a health care provider for you and your family. Consequently, we must collect information about you to provide these services. We are required to protect your information according to federal and state law and will abide by the terms of this notice. We may use and disclose information without your authorization for the following purposes:

  • Treatment Purposes. We may use or disclose your information to health care providers who are involved in your health care.
  • Payment. We may use or disclose your information to get payment or pay for health care services you received or will receive.
  • Health Care Operations. We may use or disclose your information in order to manage our business, improve your care and contact you when necessary.
  • As Required by Law. We will disclose information to a public health agency that maintains vital records, such as births, deaths and some diseases.
  • Abuse and Neglect Investigations. We may disclose your information to report all potential cases of abuse and/or neglect.
  • Health Oversight Activities. We may use or disclose your information to respond to an inspection or investigation by state officials.
  • Government Programs. We may use and disclose your information for the management and coordination of public benefits under government programs.
  • To Avoid Harm. We may use and disclose information to law enforcement in order to avoid a serious threat to the health and safety of a person or the public.
  • For Research. We may use and disclose your information for studies and to develop reports. These reports will not specifically identify you or another person.
  • Business Associates. We may use and disclose your information to our business associates that perform functions on our behalf, if necessary to complete those functions.
  • Organ and Tissue Donation. If you are an organ donor, we may use and disclose your information to organizations engaged in procuring, banking or the transportation of organs, eyes, or other tissues to facilitate organ transplantation.
  • Military and Veterans. If you are a member of the armed forces, we may disclose your information to the appropriate military authority.
  • Workers Compensation. We may use or disclose your information for workers compensation or similar programs providing benefits for work-related injuries or illnesses.
  • Data Breach Notification Purposes. We may use or disclose your information to provide legally required notices of unauthorized access or disclosure of your health information.
  • Lawsuits and Disputes. We may use or disclose your information in response to a Court or Administrative Order, subpoena, discovery request or other lawful process.
  • Law Enforcement. We may disclose your information to law enforcement if the information: 1) is in response to a court order, subpoena, warrant or similar process; 2) limited to identify or locate a suspect, fugitive, material witness or missing person; 3) about a victim of a crime under very limited circumstances; 4) about a death potentially resulting from a crime; 5) about criminal conduct on any DHS property and; 6) is needed in an emergency to report a crime or facts surrounding a crime.
  • Coroner, Medical Examiners and Funeral Directors. We may disclose your information to a Coroner or Medical Examiner to identify a deceased person or determine the cause of death. We may release your information to a Funeral Director as necessary for their duties.
  • National Security and Intelligence. We may disclose your information to authorized federal officials for intelligence, counter-intelligence and other national security activities authorized by law.
  • Protective Services for the President and Others. We may disclose your information to authorized federal officials so that they can provide protection to the U.S. President; other authorized persons or foreign heads of state, or to conduct special investigations.
  • Inmates or Individuals in Custody. If you are an inmate, we may release your information to a correctional institution if that information would be necessary for the institution to: 1) provide you with health care; 2) protect your health and safety or the health and safety of others or: 3) for the safety and security of the correctional institutions.
  • Disclosure to Family, Friends and Others. We may disclose your information to your family members, friends or other persons who are involved in your medical care. You may object to the sharing of this information. We may also share your information with someone legally designated as your personal representative.
  • Hospital Directory. Unless you notify us that you object, we may include certain information about you in the hospital directory in order to respond to inquiries from friends, family, clergy and others who inquire about you when you are a patient in the hospital.

Other Uses and Disclosures that Require Your Written Authorization

  • For All Other Situations. We will ask for your written authorization before using or disclosing information for any other purpose than what is mentioned above. Special circumstances that require an authorization include most uses and disclosures of your psychotherapy notes, certain disclosures of your test results for the human immunodeficiency virus or HIV, uses and disclosures of your health information for marketing purposes and for the sale of your health information with some exceptions. If you give us authorization, you can withdraw this written authorization at any time. To withdraw your authorization, please contact us at the number below. If you revoke your authorization, we will no longer use or disclose your health information as allowed by your written authorization, except to the extent that we have already relied on your authorization.
  • As Required by Other Laws. We will ask for your written authorization to comply with other laws protecting the use and disclosure of your information.

FILING A COMPLAINT

You may use the contact information below if you want to file a complaint or to report a problem regarding the use or disclosure of your health information. Treatment or services being provided to you will not be affected by any complaints you make. DHS opposes any retaliatory acts resulting from participation in an HIPAA investigation.

New Jersey Department of Human Services

Division of Developmental Disabilities

Legal and Administrative Practice Office

P.O. Box 726

 

222 South Warren St.

Trenton, NJ 08625-0726

Phone: 609-633-7402

DHS or its appropriate Division will respond to your communication within thirty (30) days.

CHANGES TO THIS NOTICE

In the future, DHS may change its Notice of Privacy Practices. Any change could apply to medical information we already have about you, as well as information we receive in the future. A copy of a new notice will be posted in our facilities/offices and provided to you as required by law. You may ask for a copy of our current notice or get it online on our website.

U.S. Department of Health and Human Services

Office of Civil Rights

200 Independence Ave, S.W., Room 509H

Washington DC, 20201

Phone: 866-627-7748/ TTY: 886-788-4989

www.hhs.gov/ocr

 Download notice of privacy practices

Section I: (Form B) Authorization for Disclosure of Health Information to Family & Involved Persons

Understandings and Agreements About This Authorization: 

Note: A complete copy of this authorization will be maintained in the applicant’s record.

Section J: (Form C) Authorization for Release of Medical Records (DDD to Third Party)

This form is about releasing information from DDD/PerformCare to third party providers/agencies.

Individual whose records are being requested. (This release applies to the following individual): 
  , Date of Birth: 

Request medical records for the following date range

Examples:
  - Primary care notes
  - Hospital discharge summaries
  - Psychological/psychiatric evaluations
  - Medication lists
  - Lab and imaging reports

Examples: 
    - Eligibility determination for NJ DDD services 
    - Care coordination
    - Insurance review
    - Legal proceedings.

Understandings and Agreements About This Authorization: 

Section K: (Form D) Consent for Release of Information to DDD

This form is about releasing information to DDD from other providers/agencies. Keep it distinct from Form C (which is about releasing records from DDD/PerformCare to others).

Individual whose information is being requested. (This consent applies to the following individual): 
  , Date of Birth: 

Example: To release reports, evaluations, summaries, or other information regarding the individual’s Application for Determination of Eligibility for services through the NJ Division of Developmental Disabilities (DDD).

Include full name and organization.
Examples: 
- Dr. Jane Smith
- ABC Psychological Services
- St. Mary’s Hospital, Medical Records Department

Examples: 
  - Type 'All' for all documentation OR 
  -  Psychological evaluation dated MM/DD/YYYY
  - Neuropsychological testing results
  - School records (IEP, evaluations)
  - Medical records related to [condition]
  - Any records relevant to developmental disability eligibility

For Office Use Only:(DDD Intake worker will fill the following information) Where to send the information (DDD intake details)
The information should be released to the DDD Intake Worker and office below:

Note: The information received through this release is subject to the confidentiality regulations of the Division and cannot be released outside the Division without written permission unless otherwise provided by N.J.A.C. 10:41 et seq.

Section L: Applicant Declaration

This section is the applicant’s legal attestation for the entire DDD eligibility application.

In accordance with the Revised Statutes of the State of New Jersey, Section 30:4‑25.2, an application is being made to the Commissioner of the Department of Human Services for a determination of eligibility for services provided through the NJ Division of Developmental Disabilities (DDD) for:  , Date Of Birth: 

BY SIGNING THIS APPLICATION, I AM DECLARING THAT:

Application for Determination of Eligibility (V5)

Use these links for help completing your application: Application Checklist, User Guide or Email: DDD.NJApply@dhs.nj.gov 

Section M – Voter Registration Opportunity

The National Voter Registration Act of 1993 requires the State to provide you with the opportunity to register to vote as an additional service offered by this office. Please complete the form below to advise the agent of your interest to register or not to register to vote at this time. 

Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency. 

If you decline to register to vote at this time, your decision will remain confidential and will be used only for voter registration purposes. If you do register to vote, the way in which you do so will remain confidential and will be used only for voter registration purposes. 

You can register to vote if:  

  •  You are a United States citizen  
  •  You are at least 17 years of age*  
  •  You will be a resident of the State and county 30 days before the election  
  •  You are NOT currently serving a sentence of incarceration as the result of a conviction of any indictable offense under the laws of this or another state or of the United States. 

*You may register to vote if you are at least 17 years old but cannot vote until reaching the age of 18, except that you may vote in a primary election if you are 17 and will be 18 at the time of the following general election. 

If you received this Voter Registration Opportunity form in the mail, as part of a take home packet, or during a home visit, please complete it and return it to your local County Welfare Agency (Board of Social Services). Do not send this Voter Registration Opportunity form to the Division of Elections. 

Once you complete the actual Voter Registration Application, return the application directly to your County Welfare Agency or to the Division of Elections. If you would like help filling out the Voter Registration Application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private. For assistance with the Voter Registration Application contact your local County Welfare Agency. 

If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with: the NJ Division of Elections, (mailing address) P.O. Box 304 Trenton, NJ 08625-0304; (office location) 225 West State Street, 1 st Floor, Trenton, NJ 08608; telephone 609-292-3760, fax number 609-777-1280, TTY 1-800-292-0034, elections.nj.gov

Thank you. On the next page, you will find links to download:

  1. Voter Registration Application (PDF)
  2. Your Submitted Application — You may download and save a copy for your records.

When you are ready, select Submit to send your application to the New Jersey Division of Developmental Disabilities.

Thank you. On the next page, you will find links to download:

  1. Your Submitted Application — You may download and save a copy for your records.

When you are ready, select Submit to send your application to the New Jersey Division of Developmental Disabilities.