Get State Of New Jersey Department Of The Treasury - State Nj

Filling out the State of New Jersey Department of the Treasury form can be straightforward when you have a clear guide. This document serves as an authorization to disclose health information, necessary for determining eligibility for disability retirement.

Follow the steps to complete your authorization form effectively.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by entering the patient’s name in the designated field. Make sure to type the full legal name as it appears on official documents.
3. Next, fill in the date of birth in the specified section. Use the format MM/DD/YYYY to avoid any confusion.
4. Provide the patient’s address, including street, city, state, and zip code. This information should be current to ensure proper communication.
5. Enter the telephone number where the patient can be reached. Ensure this number is accurate and up to date.
6. Select the appropriate entity that will release health information by checking the relevant box for Hospital, Employer’s Doctor's Evaluations, or Workers’ Compensation Center.
7. Specify the timeline for the treatment records by filling out the 'From' and 'To' dates in the designated fields, ensuring they accurately encompass the treatment period.
8. Indicate which specific records need to be included by checking all relevant boxes, such as Emergency Room Records, Complete Record, or others as applicable.
9. Review the authorization statement, which outlines the purpose and limitations of information disclosure. Ensure you understand your rights regarding revocation of this authorization.
10. Finally, sign and date the form at the bottom. Make sure your signature matches the name provided at the top of the form. Afterward, you can save changes, print the form, or share it as needed.

Complete your documents online today for a smooth filing experience.