AGENCY: Department of Health. Division of Medicaid and Health Financing. Bureau of Authorization and Community Based Services
SERIES: 8133
TITLE: Third-party liability questionnaire
DATES: 1982-
ARRANGEMENT: None
DESCRIPTION: This is a questionnaire filled out by medicaid applicants to determine whether they have any other sources of medical support. This is used to ensure that assistance is not given when other sources of coverage is available. This form is also used as an input document to the MMIS data system. It includes the client's name, date of birth, sex, case number, the type of coverage, the recipient's name, date of birth, sex, recipient identification number, the type of coverage, if the client has health insurance, the name and address of the insurance company, the name of the policy holder, the policy number, the name and address of the employer or group offering the coverage, whether the health insurance is through employment, whether the client has sustained any injuries in the past year, whether the client is eligible for medicare and the medicare number, whether the insurance or medical support is court ordered, and, if so, the absent parent's name, address, social security number, and date of birth, the signature and telephone number of the client, and the date signed.
RETENTION
Retain for 4 year(s)
DISPOSITION
Destroy.
RETENTION AND DISPOSITION AUTHORIZATION
Retention and disposition for this series were specifically approved by the State Records Committee.
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 information is subject to federal audit. The audit period is three years, but as the federal government operates on a fiscal year, these records should be kept for 4 calendar years. The record needs to be kept in the office only long enough to verify that the information on the form was correctly input into the system.
PRIMARY DESIGNATION
Private