AGENCY: Department of Health. Division of Medicaid and Health Financing. Bureau of Authorization and Community Based Services

SERIES: 8128
TITLE: Credit form
DATES: 1985-
ARRANGEMENT: None

DESCRIPTION: This is a data input form used to credit the accounts of health care providers. It includes the transaction code number to be adjusted, the provider and recipient identification numbers to be adjusted, the dates of service to be adjusted, the reason for the adjustment, the date of approval, and the signature of the approving official.

RETENTION

Retain for 6 month(s)

DISPOSITION

Destroy.

RETENTION AND DISPOSITION AUTHORIZATION

These records are in Archives' permanent custody.

APPROVED: 08/1986

FORMAT MANAGEMENT

Paper: Retain in Office for 6 months and then destroy.

APPRAISAL

Administrative

After input into the system, this record is sent to the Bureau of Medical Payments for microfilming. As a microfilm copy exists, the paper copy need only be kept until the accuracy of the information input into the system is verified.

PRIMARY DESIGNATION

Private

---