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right000left1905000NJ Department of Human ServicesDivision of Developmental Disabilitieshumanservices/dddRequest to Submit Voucher for PaymentDate: FORMTEXT ????? ?????AGENCY INFORMATIONAgency Name: FORMTEXT ?????(Check one): Support Coordination Agency FORMTEXT ?????Provider Agency FORMTEXT ?????Agency Representative Name: FORMTEXT ?????Email Address: FORMTEXT ?????INDIVIDUAL & SERVICE INFORMATIONDDD ID: FORMTEXT ?????First Name Initial / Last Name Initial FORMTEXT ????? Waiver Program (Check one): CCP FORMTEXT ????? Supports Program FORMTEXT ????? Supports Program + PDN FORMTEXT ????? Waiver Service(s) Provided:Start DateEnd Date (1) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????(2) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????(3) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????(4) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????MEDICAID INFORMATIONMedicaid Termination Date: FORMTEXT ?????Reason for Termination: FORMTEXT ?????Please describe efforts made to reinstate Medicaid: FORMTEXT ?????FOR DDD USE ONLYVoucher Request Status: Approved FORMTEXT ?????Denied: FORMTEXT ????? Month(s) /Year Voucher is approved: FORMTEXT ?????Comments: FORMTEXT ?????Determination made by (DDD staff): FORMTEXT ?????Title: FORMTEXT ?????Date: FORMTEXT ????? MEDICAID INFORMATIONDate Medicaid Only Application submitted to Medicaid by Waiver Unit (if applicable): FORMTEXT ????? Date Medicaid Reinstated: FORMTEXT ????? ................
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