N.J. Admin. Code Tit. 10, ch. 49, app APPENDIX - APPENDIX

Health Benefits Identification (HBID) Card	Form #1
HBID Emergency Services Letter	Form #1A
Medically Needy Claim Transmittal (FD-311)	Form #2
Public Assistance Inquiry (PA-1C)	Form #3
One Page NJ FamilyCare Presumptive Eligibility	Form #4
Application
One-Page NJ FamilyCare Application	Form #5
Retroactive Eligibility Application	Form #6
Validation of Eligibility (FD-34)	Form #7
Provider Application (FD-20)	Form #8
One Time Enrollment Application (FD-20A)	Form #8A
Provider Agreement (FD-62)	Form #9
Disclosure of Ownership and Control Interest	Form #10
Statement (CMS-1513)
Patient Certification Form (FD-197)	Form #11
Notice to All Applicants and Providers	Form #12
Medical Assistance Customer Centers Directory	Form #13
New Jersey County Welfare Agencies	Form #14

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Notes

N.J. Admin. Code Tit. 10, ch. 49, app APPENDIX

Amended by R.1997 d.354, effective 9/2/1997.
See: 29 N.J.R. 2512(a), 29 N.J.R. 3856(a).
Repealed Forms 7, 15 and 16, and recodified Forms 8 through 14, and 17, as Forms 7 through 13, and 14, respectively; and added Form 158.
Amended by R.2003 d.82, effective 2/18/2003.
See: 34 N.J.R. 2650(a), 35 N.J.R. 1118(a).
Amended by R.2006 d.25, effective 1/17/2006.
See: 37 N.J.R. 3176(a), 38 N.J.R. 802(a).
In Form 10, replaced (HCFA-1513) forms with (CMS-1513) forms.
Amended by R.2008 d.230, effective 8/4/2008.
See: 40 N.J.R. 984(a), 40 N.J.R. 4531(a).
Updated the list of forms at the beginning of the appendix; repealed former Forms 1, 4, 5, 6, 8, 9 and 14 and adopted each as new rules;
adopted Forms 1A, 8A and 13 as new rules; amended Form #3 to relocate the designation "Form #3" to the final page; amended Form #10 to include the designation "Form #10" on the final page; and repealed Form 15.