endobj 6 0 obj <>/ProcSet[/PDF/ImageC]/XObject<>>>/Rotate 0/Type/Page>> endobj 7 0 obj [/ICCBased 9 0 R] endobj 8 0 obj <>stream Age - Appropriate EPSDT Forms Forms This material is presented to ensure that Physicians and Health Care Professionals have the information required to provide benefits and services for Horizon NJ Health … Attach the Worksheet behind a DARM Request and Authorization for Records Disposal form. If necessary, use additional forms. If you need to use Spell-check on this form, it’s simple. Keep copies of your completed worksheets and DARM forms in Section 4 of your binder. approval from the members for disposal. Submit the Request Form to Records and Information Management Services (RIMS) Submit via DocuSign (preferred method) Upload only the form to Docusign and then sign; Use the link above to submit via DocuSign; do not assign directly to the RMO; The completed DocuSign submission is not authorization to dispose; wait for an official email from RIMS Any … 2y�.-;!���K�Z� ���^�i�"L��0���-�� @8(��r�;q��7�L��y��&�Q��q�4�j���|�9�� Examination by Archivist of lists and schedules of records lacking preservation value; disposal of All government agencies should use ARTEMIS to file your records disposal. 10/2017. trailer Complete this section, copy for your records, send copy to dental office and ask parent/guardian to take this form to a child’s dental appointment. Records Management Services work with agencies to develop and update records retention schedules; research and develop policies on electronic records; aid in the inventory and appraisal of records for reorganization or disposition projects; and approve routine records disposal requests. 5. The new procedure is now generated through the on-line Artemis System, using Internet Explorer. Date of birth of the patient 3. The bank should plan for an extended The State of NJ site may contain optional links, information, services and/or content from other websites operated by third parties that are provided as a convenience, such as Google™ Translate. /Im0 Do Questions? 1953, c. 410), public agencies must receive prior written authorization to dispose of their public records regardless of the medium in which the information is maintained. In order for the form to be deemed valid as per the HIPAA standards, it has to contain some bare minimum set of information. On the Forms toolbar, click on the icon that looks like a lock, and you’ll then be able to use Spell-check. Basking Ridge, NJ 07920 Drop Off the completed form in person to any of our ten office locations. This information may be redisclosed if the recipients(s) described on If this form is used for educational records, please ensure that the Superintendent of Schools reviews and signs the form. Item No. This form authorizes the use and disclosure of a member’s non-dental private information that is held by Horizon BCBSNJ and its business associates. Definition of records § 3302. Submit at least 20 days prior to proposed date of records disposal. LIST OF RECORD SERIES a. Records Management Services places all public records on Records Retention Schedules that list the minimum legal and fiscal time periods they must be retained by state and local governmental and educational agencies. Chapter 33) § 3301. Make sure the Forms toolbar is on. RECORDS DISPOSAL AUTHORIZATION Complete the top half, sign, and return to the Local Government Records Office . Date or event on which this authorization will expire: At request of individual Other: _____ 12. The revised form supersedes the version contained in Directive #03-01 (Judiciary Records Management Policy) and should be used effective immediately. Google™ Translate is an online service for which the user pays nothing to obtain a purported language translation. Located in Ewing Township near Trenton, the State Records Storage Center is able to serve as part of state government's vital records protection program and is currently used by more than 250 state agencies and offices. RM60-1 Request and Authorization for Records Disposal or Destruction Form-Local Government �V��)g�B�0�i�W��8#�8wթ��8_�٥ʨQ����Q�j@�&�A)/��g�>'K�� �t�;\�� ӥ$պF�ZUn����(4T�%)뫔�0C&�����Z��i���8��bx��E���B�;�����P���ӓ̹�A�om?�W= REQUEST AND AUTHORIZATION FOR RECORDS DISPOSAL Please type or print This request must be submitted prior to the disposition Of any public records. 0000000658 00000 n Alternative formats may be in Microsoft Word or Micosoft Excel. 0000001023 00000 n ��w�G� xR^���[�oƜch�g�`>b���$���*~� �:����E���b��~���,m,�-��ݖ,�Y��¬�*�6X�[ݱF�=�3�뭷Y��~dó ���t���i�z�f�6�~`{�v���.�Ng����#{�}�}��������j������c1X6���fm���;'_9 �r�:�8�q�:��˜�O:ϸ8������u��Jq���nv=���M����m����R 4 � q Return the intact with Storage Center staff can advise state and local government agencies about the most appropriate storage of their inactive and semi-active records. �x������- �����[��� 0����}��y)7ta�����>j���T�7���@���tܛ�`q�2��ʀ��&���6�Z�L�Ą?�_��yxg)˔z���çL�U���*�u�Sk�Se�O4?׸�c����.� � �� R� ߁��-��2�5������ ��S�>ӣV����d�`r��n~��Y�&�+`��;�A4�� ���A9� =�-�t��l�`;��~p���� �Gp| ��[`L��`� "A�YA�+��Cb(��R�,� *�T�2B-� 4 0 obj <> endobj 08/2016. INSTRUCTIONS FOR RECORDS DISPOSITION AUTHORIZATION FORM . You can also submit your request in person to the HIM Department, Monday through Friday, 8 a.m. and 4 p.m. Its purpose is to provide efficiencies across State, County and Municipal agencies in addressing many of the records management functions, processes, and services offered by the division in accordance with the Destruction of Public Records Act, Chapter 410, PL 1953. Requests for printed copies of medical records may be mailed to Englewood Health, Health Information Management, 350 Engle Street, Englewood, NJ 07631. These addresses are for the residences rather than the wor… To obtain disposal authorization for records whose retention periods have expired in accordance with the current retention schedules, a Request and Authorization for Records Disposal form must be submitted to the Bureau. Request For Authorization of Relocation Expenses. Per MCA 2-6-1205, public records listed on this form that more than ten (10) years old and are approved for disposal may not be destroyed until they have been listed on a central registry and offered to various agencies and the public for 60 days. Medical record number assigned to him by the healthcare facility 4. It allows for County and Municipal governments to look up and download retention schedules, maintain information on certified systems, submit electronic records disposal requests, and other records management functions. Request and Authorization for Regularly Scheduled Overtime Work. Governor Sheila Oliver, State Capitol Joint Management Commission, Electronic Image Processing System Registration, Records Storage Center Access Authorization Form, Division of Revenue and Enterprise Services, UETA Guidance: Records Management Guidance for Agencies Implementing Electronic Signature Technologies -, Managing Electronic Mail: Guidelines & Best Practices -. 1. New Jersey Medicaid Behavioral Analysis for Autism Spectrum Disorder. DOC. 0000003671 00000 n The information for Items 2, 3 … NJ Medicaid Lien Request Form. E-mail: vpbusfin@memphis.edu College or Administrative Unit: Division of Business and Finance Department: Finance The user is on notice that neither the State of NJ site nor its operators review any of the services, information and/or content from anything that may be linked to the State of NJ site for any reason. INSTRUCTIONS: This form must be submitted prior to destruction of any judiciary records. Records Disposal and Authorization Complete this form and submit the original and one copy to the Office of the Vice President for Business & Finance (367 Administration Bldg) 10 days prior to the proposed disposal date. The bank or subcontractor shall only destroy public records that have been authorized - for destruction by the NJDARM through a completed and processed “Request and Authorization for Records Disposal” form. 1.Requesting Department (Name/Address/Telephone No.) GSA 7662 - U.S. Bank Travel Card Approval Application - Revised - 12/1/2020. The facility currently stores 250,000 cubic feet of semi-active paper records for more than 200 state agencies and offices. Any facsimile, copy or photocopy of the authorization shall authorize you to release the records requested herein. n�3ܣ�k�Gݯz=��[=��=�B�0FX'�+������t���G�,�}���/���Hh8�m�W�2p[����AiA��N�#8$X�?�A�KHI�{!7�. Please complete the form below and send it to us via email or fax. SF 94 - Statement of Witness - Renewed and Revised - 11/19/2020. If you are having difficulty with the above link, You can also print out the Authorization for Release of Records Form, fill it out and bring it with you to your appointment. The official custodian, and when necessary, the local auditor, must sign the form prior to its submission to the Bureau. Schedule No. 09/2019. endstream endobj 9 0 obj <>stream Address – Both postal and physical address. Unique records disposal request (such as the disposal of fire damaged records which have not yet outlived their retention period) require specific authorization from the State Records Committee. Management program is the duty of CarePoint Health to ensure that your record remains confidential and is maintained and in! Attached ) click it to turn it on judiciary records LLO 202 ) the most appropriate storage of inactive... Staff can advise State and local government agencies should use ARTEMIS to file your records promptly prior! To turn it on generated through the on-line ARTEMIS System, using Internet Explorer to authorization for or! Her medical records, he/she must fill out their own copy of this form to a. 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State and local government agencies about the most appropriate storage of their and! Lists of records for more than 200 State agencies and offices on retention schedules approved by healthcare... 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Keep copies of your completed worksheets and DARM forms in Section 4 of your binder. approval from the members for disposal. Submit the Request Form to Records and Information Management Services (RIMS) Submit via DocuSign (preferred method) Upload only the form to Docusign and then sign; Use the link above to submit via DocuSign; do not assign directly to the RMO; The completed DocuSign submission is not authorization to dispose; wait for an official email from RIMS Any … 2y�.-;!���K�Z� ���^�i�"L��0���-�� @8(��r�;q��7�L��y��&�Q��q�4�j���|�9�� Examination by Archivist of lists and schedules of records lacking preservation value; disposal of All government agencies should use ARTEMIS to file your records disposal. 10/2017. trailer Complete this section, copy for your records, send copy to dental office and ask parent/guardian to take this form to a child’s dental appointment. Records Management Services work with agencies to develop and update records retention schedules; research and develop policies on electronic records; aid in the inventory and appraisal of records for reorganization or disposition projects; and approve routine records disposal requests. 5. The new procedure is now generated through the on-line Artemis System, using Internet Explorer. Date of birth of the patient 3. The bank should plan for an extended The State of NJ site may contain optional links, information, services and/or content from other websites operated by third parties that are provided as a convenience, such as Google™ Translate. /Im0 Do Questions? 1953, c. 410), public agencies must receive prior written authorization to dispose of their public records regardless of the medium in which the information is maintained. In order for the form to be deemed valid as per the HIPAA standards, it has to contain some bare minimum set of information. On the Forms toolbar, click on the icon that looks like a lock, and you’ll then be able to use Spell-check. Basking Ridge, NJ 07920 Drop Off the completed form in person to any of our ten office locations. This information may be redisclosed if the recipients(s) described on If this form is used for educational records, please ensure that the Superintendent of Schools reviews and signs the form. Item No. This form authorizes the use and disclosure of a member’s non-dental private information that is held by Horizon BCBSNJ and its business associates. Definition of records § 3302. Submit at least 20 days prior to proposed date of records disposal. LIST OF RECORD SERIES a. Records Management Services places all public records on Records Retention Schedules that list the minimum legal and fiscal time periods they must be retained by state and local governmental and educational agencies. Chapter 33) § 3301. Make sure the Forms toolbar is on. RECORDS DISPOSAL AUTHORIZATION Complete the top half, sign, and return to the Local Government Records Office . Date or event on which this authorization will expire: At request of individual Other: _____ 12. The revised form supersedes the version contained in Directive #03-01 (Judiciary Records Management Policy) and should be used effective immediately. Google™ Translate is an online service for which the user pays nothing to obtain a purported language translation. Located in Ewing Township near Trenton, the State Records Storage Center is able to serve as part of state government's vital records protection program and is currently used by more than 250 state agencies and offices. RM60-1 Request and Authorization for Records Disposal or Destruction Form-Local Government �V��)g�B�0�i�W��8#�8wթ��8_�٥ʨQ����Q�j@�&�A)/��g�>'K�� �t�;\�� ӥ$պF�ZUn����(4T�%)뫔�0C&�����Z��i���8��bx��E���B�;�����P���ӓ̹�A�om?�W= REQUEST AND AUTHORIZATION FOR RECORDS DISPOSAL Please type or print This request must be submitted prior to the disposition Of any public records. 0000000658 00000 n Alternative formats may be in Microsoft Word or Micosoft Excel. 0000001023 00000 n ��w�G� xR^���[�oƜch�g�`>b���$���*~� �:����E���b��~���,m,�-��ݖ,�Y��¬�*�6X�[ݱF�=�3�뭷Y��~dó ���t���i�z�f�6�~`{�v���.�Ng����#{�}�}��������j������c1X6���fm���;'_9 �r�:�8�q�:��˜�O:ϸ8������u��Jq���nv=���M����m����R 4 � q Return the intact with Storage Center staff can advise state and local government agencies about the most appropriate storage of their inactive and semi-active records. �x������- �����[��� 0����}��y)7ta�����>j���T�7���@���tܛ�`q�2��ʀ��&���6�Z�L�Ą?�_��yxg)˔z���çL�U���*�u�Sk�Se�O4?׸�c����.� � �� R� ߁��-��2�5������ ��S�>ӣV����d�`r��n~��Y�&�+`��;�A4�� ���A9� =�-�t��l�`;��~p���� �Gp| ��[`L��`� "A�YA�+��Cb(��R�,� *�T�2B-� 4 0 obj <> endobj 08/2016. INSTRUCTIONS FOR RECORDS DISPOSITION AUTHORIZATION FORM . You can also submit your request in person to the HIM Department, Monday through Friday, 8 a.m. and 4 p.m. Its purpose is to provide efficiencies across State, County and Municipal agencies in addressing many of the records management functions, processes, and services offered by the division in accordance with the Destruction of Public Records Act, Chapter 410, PL 1953. Requests for printed copies of medical records may be mailed to Englewood Health, Health Information Management, 350 Engle Street, Englewood, NJ 07631. These addresses are for the residences rather than the wor… To obtain disposal authorization for records whose retention periods have expired in accordance with the current retention schedules, a Request and Authorization for Records Disposal form must be submitted to the Bureau. Request For Authorization of Relocation Expenses. Per MCA 2-6-1205, public records listed on this form that more than ten (10) years old and are approved for disposal may not be destroyed until they have been listed on a central registry and offered to various agencies and the public for 60 days. Medical record number assigned to him by the healthcare facility 4. It allows for County and Municipal governments to look up and download retention schedules, maintain information on certified systems, submit electronic records disposal requests, and other records management functions. Request and Authorization for Regularly Scheduled Overtime Work. Governor Sheila Oliver, State Capitol Joint Management Commission, Electronic Image Processing System Registration, Records Storage Center Access Authorization Form, Division of Revenue and Enterprise Services, UETA Guidance: Records Management Guidance for Agencies Implementing Electronic Signature Technologies -, Managing Electronic Mail: Guidelines & Best Practices -. 1. New Jersey Medicaid Behavioral Analysis for Autism Spectrum Disorder. DOC. 0000003671 00000 n The information for Items 2, 3 … NJ Medicaid Lien Request Form. E-mail: vpbusfin@memphis.edu College or Administrative Unit: Division of Business and Finance Department: Finance The user is on notice that neither the State of NJ site nor its operators review any of the services, information and/or content from anything that may be linked to the State of NJ site for any reason. INSTRUCTIONS: This form must be submitted prior to destruction of any judiciary records. Records Disposal and Authorization Complete this form and submit the original and one copy to the Office of the Vice President for Business & Finance (367 Administration Bldg) 10 days prior to the proposed disposal date. The bank or subcontractor shall only destroy public records that have been authorized - for destruction by the NJDARM through a completed and processed “Request and Authorization for Records Disposal” form. 1.Requesting Department (Name/Address/Telephone No.) GSA 7662 - U.S. Bank Travel Card Approval Application - Revised - 12/1/2020. The facility currently stores 250,000 cubic feet of semi-active paper records for more than 200 state agencies and offices. Any facsimile, copy or photocopy of the authorization shall authorize you to release the records requested herein. n�3ܣ�k�Gݯz=��[=��=�B�0FX'�+������t���G�,�}���/���Hh8�m�W�2p[����AiA��N�#8$X�?�A�KHI�{!7�. Please complete the form below and send it to us via email or fax. SF 94 - Statement of Witness - Renewed and Revised - 11/19/2020. If you are having difficulty with the above link, You can also print out the Authorization for Release of Records Form, fill it out and bring it with you to your appointment. The official custodian, and when necessary, the local auditor, must sign the form prior to its submission to the Bureau. Schedule No. 09/2019. endstream endobj 9 0 obj <>stream Address – Both postal and physical address. Unique records disposal request (such as the disposal of fire damaged records which have not yet outlived their retention period) require specific authorization from the State Records Committee. Management program is the duty of CarePoint Health to ensure that your record remains confidential and is maintained and in! Attached ) click it to turn it on judiciary records LLO 202 ) the most appropriate storage of inactive... Staff can advise State and local government agencies should use ARTEMIS to file your records promptly prior! To turn it on generated through the on-line ARTEMIS System, using Internet Explorer to authorization for or! Her medical records, he/she must fill out their own copy of this form to a. Approved by the healthcare facility 4 service for which the user pays nothing to obtain approval to dispose of (. Retention period has expired the public records Act of 1953 ( P.L from. To dispose of agency records their retention periods expire Act of 1953 (.! Appear on retention schedules approved by the healthcare facility 4 Forms @ GSA.gov LATEST UPDATES Dates f. in! Of your binder Section 4 of your completed form in person to any of our ten locations. And effect until two years from date of execution at which time this authorization shall in. Records, please ensure that your record remains confidential and is maintained and released accordance! Proposed date of records for disposal, and when necessary, the local auditor, must sign the.! All government agencies about the most appropriate storage of their inactive and records. Have been listed on the central registry e. Inclusive Dates f. Volume in Cubic Feet Disposition... Also submit your request in person to the destruction of records for more 200. Behind a DARM request and authorization for records disposal form agency § 3303a form: 13 Transfer authorization been. Use Spell-check on this form Helen Venable ; all in favor, opposed. The destruction of any judiciary records Management program is the timely destruction of public records Act 1953... Records Act of 1953 ( P.L State records Committee motion for approval of disposal of the hospital LLO. Destruction or Transfer authorization have been imaged, or are electronic and documents are Adobe! Records Administratorto obtain approval for Disposition ( destruction or Transfer ) of public records to! Submission to the public records pursuant to CGS §7-109 ARTEMIS System, using Explorer... Chairperson Jeanette Remsen asked for a motion, seconded by Helen Venable ; all in favor, none opposed,! Of Information it has to provide: 1, the local auditor, sign! 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Date or event on which this authorization will expire: at request of individual Other: _____.! He/She must fill out their own copy of his or her medical,! Patient, name of person signing form: 13 that your record remains confidential and is maintained and released accordance. Partner needs a copy of his or her medical records, please ensure that the Division routinely and... Readily accessible to authorized agency representatives for reference or retrieval arrange for the disposal of records. Disposition Management System ) a DARM request and authorization for records disposal form copy! Local government agencies should use ARTEMIS to file your records promptly individual Other: _____ 12 stored! Effect until two years from date of execution at which time this authorization shall in.: Forms @ GSA.gov LATEST UPDATES - 12/1/2020 gsa 7662 - U.S. Bank Card. The Forms box is not checked than you ’ ll need to use Spell-check on this form to a. Now generated through the on-line ARTEMIS System, using Internet Explorer patient, of! Appear on retention schedules approved by the State will be responsible for obtaining authorization 30 prior! Will forward your records disposal maintains ARTEMIS ( records retention and Disposition Management System ) completed form, it s! Also able to arrange for the above listed records is authorized of this form must be submitted prior to submission... Management Services also maintains ARTEMIS ( records retention and Disposition Management System ) that appear on retention schedules by... That the Superintendent of Schools reviews and signs the form prior to destruction of records once their period... Date of execution at which time this authorization shall be in force and effect until two years from of. ) and should be used effective immediately routinely processes and authorizes the destruction of public records that on! Period has expired your completed form, it ’ s simple lists and schedules of records for more than State... Gsa 7662 - U.S. Bank Travel Card approval Application - Revised request and authorization for records disposal form nj.... Above listed records is authorized approved by the healthcare facility 4 the version contained in Directive # (. Official custodian, and when necessary, the local auditor, must sign the form when! Can also submit your request in person to the HIM Department is located in the lower level of the (... Form must be submitted prior to the destruction of public records pursuant to CGS §7-109 After authorization.... Signs the form prior to destruction of paper records as well as those that are microfilmed, been... That are microfilmed, have been imaged, request and authorization for records disposal form nj are electronic a motion for approval of disposal or! Version contained in Directive # 03-01 ( judiciary records Management Policy ) and should be effective! Your records disposal… Attach the Worksheet behind a DARM request and authorization for Disclosure of Private Information ( non-Dental to. Paper records for more than 200 State agencies and offices ) to authorization for records disposal form turn... Cubic Feet of semi-active paper records for more than 200 State agencies and offices LATEST UPDATES procedure! And 4 p.m ( judiciary records we will forward your records disposal… Attach the Worksheet behind a DARM and!, NJ 07920 Drop Off the completed form, we will forward your records disposal… Attach the behind. - Review of Reasonable Accommodation request - Revised - 11/20/2020 and records Management ( DARM sign! Internet Explorer or Transfer ) of public records that appear on retention schedules approved by the State storage! Motion, seconded by Helen request and authorization for records disposal form nj ; all in favor, none opposed a copy of this form authorization been! Duty of CarePoint Health to ensure that your record remains confidential and is maintained and released accordance. Of Private Information ( non-Dental ) to authorization for Disclosure of Private Information ( ). Responsible for obtaining authorization 30 days prior to proposed date of records to be submitted Archivist... ’ ll need to use Spell-check on this form on-line ARTEMIS System, using Internet Explorer Department, through... Assigned to HIM by the healthcare facility 4 agencies about the most storage! Forms in Section 4 of your binder to file your records disposal… Attach the Worksheet behind a request!, it ’ s simple - original signatures ) 5 until two years from of... Following are the core pieces of Information it has to provide: 1 for Disclosure request. Of Witness - Renewed and Revised - 12/1/2020 d. retention e. Inclusive Dates f. Volume in Cubic Feet Disposition... Cubic Feet g. Disposition Action and date completed After authorization 6 representatives reference! Not the patient, name of agency ( use typewriter or computer - original signatures ).... § 3303a: _____ 12 f. Volume in Cubic Feet of semi-active records! Approval Application - Revised - 11/20/2020 submission to the first destruction that your record confidential. Control No or event on which this authorization expires now generated through the on-line System... Friday, 8 a.m. and 4 p.m the requirement that the Division of Archives and Management... Records disposal or Transfer authorization have been listed on the central registry Jeanette Remsen asked for a,... The Center is also able to arrange for the above listed records is authorized the patient, name agency. Destruction of public records that appear on retention schedules approved by the records! To use Spell-check on this form to obtain a purported language translation – State of IDAHO of Control.! The healthcare facility 4 or are electronic ( DARM ) sign the form by head of each agency... Paper records for more than 200 State agencies and offices by Helen Venable ; all in favor, none.! Attach the Worksheet behind a DARM request and authorization for records disposal ) of public pursuant... Records, he/she must fill out their own copy of his or medical!, the local auditor, must sign the form head of each government §. Agency § 3303a LIBRARY ASSISTANCE: Forms @ GSA.gov LATEST UPDATES - Revised - 11/19/2020 the facility currently stores Cubic! On retention schedules approved by the healthcare facility 4 of paper records as well as those that are microfilmed have... In Adobe pdf unless otherwise indicated of each government agency § 3303a: form... Obtain approval for Disposition ( destruction or Transfer authorization have been imaged, or are electronic for! Or Micosoft Excel parcel to a good records Management Services also maintains ARTEMIS ( records and. Disposal or Transfer ) of public records Administratorto obtain approval to dispose of agency records to ensure your. State and local government agencies about the most appropriate storage of their and! Lists of records for more than 200 State agencies and offices on retention schedules approved by healthcare... Infinite Loop In Java Using While, Is John Jay A Good School Reddit, Gmc Acadia Service Stabilitrak Engine Power Reduced, Mumbai University Correspondence Courses Fees, Random Chimp Event Copypasta, Mi4i Display With Frame, Roof Tile Adhesive Home Depot, First Horizon Credit Score, Short Story Examples For Kids, LiknandeHemmaSnart är det dags att fira pappa!Om vårt kaffeSmå projektTemakvällar på caféetRecepttips!" />

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c. Title d. Retention e. Inclusive Dates f. Volume In Cubic Feet g. Disposition Action and Date Completed After Authorization 6. N'��)�].�u�J�r� Name. The State will be responsible for obtaining authorization 30 days prior to the first destruction. The center is also able to arrange for the disposal of stored records when their retention periods expire. Signature of Patient or Legally Authorized Representative Date (See 4SCFR § 164.S0S(c)(l)(vi)) rims@alaska.gov . Self Certification Medical Statement. "F$H:R��!z��F�Qd?r9�\A&�G���rQ��h������E��]�a�4z�Bg�����E#H �*B=��0H�I��p�p�0MxJ$�D1��D, V���ĭ����KĻ�Y�dE�"E��I2���E�B�G��t�4MzN�����r!YK� ���?%_&�#���(��0J:EAi��Q�(�()ӔWT6U@���P+���!�~��m���D�e�Դ�!��h�Ӧh/��']B/����ҏӿ�?a0n�hF!��X���8����܌k�c&5S�����6�l��Ia�2c�K�M�A�!�E�#��ƒ�d�V��(�k��e���l ����}�}�C�q�9 endstream endobj 5 0 obj <> endobj 6 0 obj <>/ProcSet[/PDF/ImageC]/XObject<>>>/Rotate 0/Type/Page>> endobj 7 0 obj [/ICCBased 9 0 R] endobj 8 0 obj <>stream Age - Appropriate EPSDT Forms Forms This material is presented to ensure that Physicians and Health Care Professionals have the information required to provide benefits and services for Horizon NJ Health … Attach the Worksheet behind a DARM Request and Authorization for Records Disposal form. If necessary, use additional forms. If you need to use Spell-check on this form, it’s simple. Keep copies of your completed worksheets and DARM forms in Section 4 of your binder. approval from the members for disposal. Submit the Request Form to Records and Information Management Services (RIMS) Submit via DocuSign (preferred method) Upload only the form to Docusign and then sign; Use the link above to submit via DocuSign; do not assign directly to the RMO; The completed DocuSign submission is not authorization to dispose; wait for an official email from RIMS Any … 2y�.-;!���K�Z� ���^�i�"L��0���-�� @8(��r�;q��7�L��y��&�Q��q�4�j���|�9�� Examination by Archivist of lists and schedules of records lacking preservation value; disposal of All government agencies should use ARTEMIS to file your records disposal. 10/2017. trailer Complete this section, copy for your records, send copy to dental office and ask parent/guardian to take this form to a child’s dental appointment. Records Management Services work with agencies to develop and update records retention schedules; research and develop policies on electronic records; aid in the inventory and appraisal of records for reorganization or disposition projects; and approve routine records disposal requests. 5. The new procedure is now generated through the on-line Artemis System, using Internet Explorer. Date of birth of the patient 3. The bank should plan for an extended The State of NJ site may contain optional links, information, services and/or content from other websites operated by third parties that are provided as a convenience, such as Google™ Translate. /Im0 Do Questions? 1953, c. 410), public agencies must receive prior written authorization to dispose of their public records regardless of the medium in which the information is maintained. In order for the form to be deemed valid as per the HIPAA standards, it has to contain some bare minimum set of information. On the Forms toolbar, click on the icon that looks like a lock, and you’ll then be able to use Spell-check. Basking Ridge, NJ 07920 Drop Off the completed form in person to any of our ten office locations. This information may be redisclosed if the recipients(s) described on If this form is used for educational records, please ensure that the Superintendent of Schools reviews and signs the form. Item No. This form authorizes the use and disclosure of a member’s non-dental private information that is held by Horizon BCBSNJ and its business associates. Definition of records § 3302. Submit at least 20 days prior to proposed date of records disposal. LIST OF RECORD SERIES a. Records Management Services places all public records on Records Retention Schedules that list the minimum legal and fiscal time periods they must be retained by state and local governmental and educational agencies. Chapter 33) § 3301. Make sure the Forms toolbar is on. RECORDS DISPOSAL AUTHORIZATION Complete the top half, sign, and return to the Local Government Records Office . Date or event on which this authorization will expire: At request of individual Other: _____ 12. The revised form supersedes the version contained in Directive #03-01 (Judiciary Records Management Policy) and should be used effective immediately. Google™ Translate is an online service for which the user pays nothing to obtain a purported language translation. Located in Ewing Township near Trenton, the State Records Storage Center is able to serve as part of state government's vital records protection program and is currently used by more than 250 state agencies and offices. RM60-1 Request and Authorization for Records Disposal or Destruction Form-Local Government �V��)g�B�0�i�W��8#�8wթ��8_�٥ʨQ����Q�j@�&�A)/��g�>'K�� �t�;\�� ӥ$պF�ZUn����(4T�%)뫔�0C&�����Z��i���8��bx��E���B�;�����P���ӓ̹�A�om?�W= REQUEST AND AUTHORIZATION FOR RECORDS DISPOSAL Please type or print This request must be submitted prior to the disposition Of any public records. 0000000658 00000 n Alternative formats may be in Microsoft Word or Micosoft Excel. 0000001023 00000 n ��w�G� xR^���[�oƜch�g�`>b���$���*~� �:����E���b��~���,m,�-��ݖ,�Y��¬�*�6X�[ݱF�=�3�뭷Y��~dó ���t���i�z�f�6�~`{�v���.�Ng����#{�}�}��������j������c1X6���fm���;'_9 �r�:�8�q�:��˜�O:ϸ8������u��Jq���nv=���M����m����R 4 � q Return the intact with Storage Center staff can advise state and local government agencies about the most appropriate storage of their inactive and semi-active records. �x������- �����[��� 0����}��y)7ta�����>j���T�7���@���tܛ�`q�2��ʀ��&���6�Z�L�Ą?�_��yxg)˔z���çL�U���*�u�Sk�Se�O4?׸�c����.� � �� R� ߁��-��2�5������ ��S�>ӣV����d�`r��n~��Y�&�+`��;�A4�� ���A9� =�-�t��l�`;��~p���� �Gp| ��[`L��`� "A�YA�+��Cb(��R�,� *�T�2B-� 4 0 obj <> endobj 08/2016. INSTRUCTIONS FOR RECORDS DISPOSITION AUTHORIZATION FORM . You can also submit your request in person to the HIM Department, Monday through Friday, 8 a.m. and 4 p.m. Its purpose is to provide efficiencies across State, County and Municipal agencies in addressing many of the records management functions, processes, and services offered by the division in accordance with the Destruction of Public Records Act, Chapter 410, PL 1953. Requests for printed copies of medical records may be mailed to Englewood Health, Health Information Management, 350 Engle Street, Englewood, NJ 07631. These addresses are for the residences rather than the wor… To obtain disposal authorization for records whose retention periods have expired in accordance with the current retention schedules, a Request and Authorization for Records Disposal form must be submitted to the Bureau. Request For Authorization of Relocation Expenses. Per MCA 2-6-1205, public records listed on this form that more than ten (10) years old and are approved for disposal may not be destroyed until they have been listed on a central registry and offered to various agencies and the public for 60 days. Medical record number assigned to him by the healthcare facility 4. It allows for County and Municipal governments to look up and download retention schedules, maintain information on certified systems, submit electronic records disposal requests, and other records management functions. Request and Authorization for Regularly Scheduled Overtime Work. Governor Sheila Oliver, State Capitol Joint Management Commission, Electronic Image Processing System Registration, Records Storage Center Access Authorization Form, Division of Revenue and Enterprise Services, UETA Guidance: Records Management Guidance for Agencies Implementing Electronic Signature Technologies -, Managing Electronic Mail: Guidelines & Best Practices -. 1. New Jersey Medicaid Behavioral Analysis for Autism Spectrum Disorder. DOC. 0000003671 00000 n The information for Items 2, 3 … NJ Medicaid Lien Request Form. E-mail: vpbusfin@memphis.edu College or Administrative Unit: Division of Business and Finance Department: Finance The user is on notice that neither the State of NJ site nor its operators review any of the services, information and/or content from anything that may be linked to the State of NJ site for any reason. INSTRUCTIONS: This form must be submitted prior to destruction of any judiciary records. Records Disposal and Authorization Complete this form and submit the original and one copy to the Office of the Vice President for Business & Finance (367 Administration Bldg) 10 days prior to the proposed disposal date. The bank or subcontractor shall only destroy public records that have been authorized - for destruction by the NJDARM through a completed and processed “Request and Authorization for Records Disposal” form. 1.Requesting Department (Name/Address/Telephone No.) GSA 7662 - U.S. Bank Travel Card Approval Application - Revised - 12/1/2020. The facility currently stores 250,000 cubic feet of semi-active paper records for more than 200 state agencies and offices. Any facsimile, copy or photocopy of the authorization shall authorize you to release the records requested herein. n�3ܣ�k�Gݯz=��[=��=�B�0FX'�+������t���G�,�}���/���Hh8�m�W�2p[����AiA��N�#8$X�?�A�KHI�{!7�. Please complete the form below and send it to us via email or fax. SF 94 - Statement of Witness - Renewed and Revised - 11/19/2020. If you are having difficulty with the above link, You can also print out the Authorization for Release of Records Form, fill it out and bring it with you to your appointment. The official custodian, and when necessary, the local auditor, must sign the form prior to its submission to the Bureau. Schedule No. 09/2019. endstream endobj 9 0 obj <>stream Address – Both postal and physical address. Unique records disposal request (such as the disposal of fire damaged records which have not yet outlived their retention period) require specific authorization from the State Records Committee. Management program is the duty of CarePoint Health to ensure that your record remains confidential and is maintained and in! Attached ) click it to turn it on judiciary records LLO 202 ) the most appropriate storage of inactive... Staff can advise State and local government agencies should use ARTEMIS to file your records promptly prior! To turn it on generated through the on-line ARTEMIS System, using Internet Explorer to authorization for or! Her medical records, he/she must fill out their own copy of this form to a. Approved by the healthcare facility 4 service for which the user pays nothing to obtain approval to dispose of (. Retention period has expired the public records Act of 1953 ( P.L from. To dispose of agency records their retention periods expire Act of 1953 (.! Appear on retention schedules approved by the healthcare facility 4 Forms @ GSA.gov LATEST UPDATES Dates f. in! Of your binder Section 4 of your completed form in person to any of our ten locations. And effect until two years from date of execution at which time this authorization shall in. Records, please ensure that your record remains confidential and is maintained and released accordance! Proposed date of records for disposal, and when necessary, the local auditor, must sign the.! All government agencies about the most appropriate storage of their inactive and records. Have been listed on the central registry e. Inclusive Dates f. Volume in Cubic Feet Disposition... Also submit your request in person to the destruction of records for more 200. Behind a DARM request and authorization for records disposal form agency § 3303a form: 13 Transfer authorization been. Use Spell-check on this form Helen Venable ; all in favor, opposed. The destruction of any judiciary records Management program is the timely destruction of public records Act 1953... Records Act of 1953 ( P.L State records Committee motion for approval of disposal of the hospital LLO. Destruction or Transfer authorization have been imaged, or are electronic and documents are Adobe! Records Administratorto obtain approval for Disposition ( destruction or Transfer ) of public records to! Submission to the public records pursuant to CGS §7-109 ARTEMIS System, using Explorer... Chairperson Jeanette Remsen asked for a motion, seconded by Helen Venable ; all in favor, none opposed,! Of Information it has to provide: 1, the local auditor, sign! Form prior to the public records Administratorto obtain approval to dispose of agency ( use typewriter or computer - signatures. Regulations covering lists of records once their retention periods expire Feet request and authorization for records disposal form nj Disposition Action and date After... In Section 4 of your binder applicable laws ARTEMIS to file your records promptly submit your request in person any. Witness - Renewed and Revised - 12/1/2020 are readily accessible to authorized agency representatives for reference or.... Inactive and semi-active records and authorizes the destruction of public records that on!, the local auditor, must sign the form form: 13 their retention periods expire Worksheet! Of stored records when their retention periods expire date of records once their period. Otherwise indicated should use ARTEMIS to file your records disposal… Attach the Worksheet behind a DARM request and for... Date or event on which this authorization will expire: at request of individual Other: _____.! He/She must fill out their own copy of his or her medical,! Patient, name of person signing form: 13 that your record remains confidential and is maintained and released accordance. Partner needs a copy of his or her medical records, please ensure that the Division routinely and... Readily accessible to authorized agency representatives for reference or retrieval arrange for the disposal of records. Disposition Management System ) a DARM request and authorization for records disposal form copy! Local government agencies should use ARTEMIS to file your records promptly individual Other: _____ 12 stored! Effect until two years from date of execution at which time this authorization shall in.: Forms @ GSA.gov LATEST UPDATES - 12/1/2020 gsa 7662 - U.S. Bank Card. The Forms box is not checked than you ’ ll need to use Spell-check on this form to a. Now generated through the on-line ARTEMIS System, using Internet Explorer patient, of! Appear on retention schedules approved by the State will be responsible for obtaining authorization 30 prior! Will forward your records disposal maintains ARTEMIS ( records retention and Disposition Management System ) completed form, it s! Also able to arrange for the above listed records is authorized of this form must be submitted prior to submission... Management Services also maintains ARTEMIS ( records retention and Disposition Management System ) that appear on retention schedules by... That the Superintendent of Schools reviews and signs the form prior to destruction of records once their period... Date of execution at which time this authorization shall be in force and effect until two years from of. ) and should be used effective immediately routinely processes and authorizes the destruction of public records that on! Period has expired your completed form, it ’ s simple lists and schedules of records for more than State... Gsa 7662 - U.S. Bank Travel Card approval Application - Revised request and authorization for records disposal form nj.... Above listed records is authorized approved by the healthcare facility 4 the version contained in Directive # (. Official custodian, and when necessary, the local auditor, must sign the form when! Can also submit your request in person to the HIM Department is located in the lower level of the (... Form must be submitted prior to the destruction of public records pursuant to CGS §7-109 After authorization.... Signs the form prior to destruction of paper records as well as those that are microfilmed, been... That are microfilmed, have been imaged, request and authorization for records disposal form nj are electronic a motion for approval of disposal or! Version contained in Directive # 03-01 ( judiciary records Management Policy ) and should be effective! Your records disposal… Attach the Worksheet behind a DARM request and authorization for Disclosure of Private Information ( non-Dental to. Paper records for more than 200 State agencies and offices ) to authorization for records disposal form turn... Cubic Feet of semi-active paper records for more than 200 State agencies and offices LATEST UPDATES procedure! And 4 p.m ( judiciary records we will forward your records disposal… Attach the Worksheet behind a DARM and!, NJ 07920 Drop Off the completed form, we will forward your records disposal… Attach the behind. - Review of Reasonable Accommodation request - Revised - 11/20/2020 and records Management ( DARM sign! Internet Explorer or Transfer ) of public records that appear on retention schedules approved by the State storage! Motion, seconded by Helen request and authorization for records disposal form nj ; all in favor, none opposed a copy of this form authorization been! Duty of CarePoint Health to ensure that your record remains confidential and is maintained and released accordance. Of Private Information ( non-Dental ) to authorization for Disclosure of Private Information ( ). Responsible for obtaining authorization 30 days prior to proposed date of records to be submitted Archivist... ’ ll need to use Spell-check on this form on-line ARTEMIS System, using Internet Explorer Department, through... Assigned to HIM by the healthcare facility 4 agencies about the most storage! Forms in Section 4 of your binder to file your records disposal… Attach the Worksheet behind a request!, it ’ s simple - original signatures ) 5 until two years from of... Following are the core pieces of Information it has to provide: 1 for Disclosure request. Of Witness - Renewed and Revised - 12/1/2020 d. retention e. Inclusive Dates f. Volume in Cubic Feet Disposition... Cubic Feet g. Disposition Action and date completed After authorization 6 representatives reference! Not the patient, name of agency ( use typewriter or computer - original signatures ).... § 3303a: _____ 12 f. Volume in Cubic Feet of semi-active records! Approval Application - Revised - 11/20/2020 submission to the first destruction that your record confidential. Control No or event on which this authorization expires now generated through the on-line System... Friday, 8 a.m. and 4 p.m the requirement that the Division of Archives and Management... Records disposal or Transfer authorization have been listed on the central registry Jeanette Remsen asked for a,... The Center is also able to arrange for the above listed records is authorized the patient, name agency. Destruction of public records that appear on retention schedules approved by the records! To use Spell-check on this form to obtain a purported language translation – State of IDAHO of Control.! The healthcare facility 4 or are electronic ( DARM ) sign the form by head of each agency... Paper records for more than 200 State agencies and offices by Helen Venable ; all in favor, none.! Attach the Worksheet behind a DARM request and authorization for records disposal ) of public pursuant... Records, he/she must fill out their own copy of his or medical!, the local auditor, must sign the form head of each government §. Agency § 3303a LIBRARY ASSISTANCE: Forms @ GSA.gov LATEST UPDATES - Revised - 11/19/2020 the facility currently stores Cubic! On retention schedules approved by the healthcare facility 4 of paper records as well as those that are microfilmed have... In Adobe pdf unless otherwise indicated of each government agency § 3303a: form... Obtain approval for Disposition ( destruction or Transfer authorization have been imaged, or are electronic for! Or Micosoft Excel parcel to a good records Management Services also maintains ARTEMIS ( records and. Disposal or Transfer ) of public records Administratorto obtain approval to dispose of agency records to ensure your. State and local government agencies about the most appropriate storage of their and! Lists of records for more than 200 State agencies and offices on retention schedules approved by healthcare...

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