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

SERIES: 8132
TITLE: Choice of health care delivery
DATES: 1982-
ARRANGEMENT: None

DESCRIPTION: This is a form filled out by medicaid applicants to choose the type of health care they wish to have. They may choose to join a Health Maintenance Organization, an Independent Practice Association, or Case Management. The form is then used as an input document for the MMIS data system. It includes the client's choice of joining a Health Maintenance Organization (HMO), an Independent Practice Association, or Case Management, the dates the client previously enrolled, and terminated one of the three choices, if the client had never previously enrolled, and the new start date, the client's identification number, name, address, telephone number, the primary health care provider's name(s), identification number(s) of client children and their provider's name, address, telephone numbers, and identification numbers, the client's signature, and date of signing, and the date the physician letter was sent.

RETENTION

Retain for 4 year(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 transfer to State Records Center. Retain in State Records Center for 4 years and then destroy.

APPRAISAL

Administrative Fiscal

This record is subject to federal audit which is three years. As the federal government operates on a fiscal rather than a calendar year basis, these records need to be kept four calendar years. They only need to be kept in the office long enough to verify that the information on them was correctly input into the system.

PRIMARY DESIGNATION

Private