D.8 REQUEST FOR EXTENSION OF PER DIEM

ATTACHMENT D.8- REQUEST FOR EXTENSION OF PER DIEM

RFQ 36C24226Q0118

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.
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:

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 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 180th day from the date of admission?
Yes

No

Does the COTR grant permission for the continuation of per diem? Yes

No