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Bureau for Medical ServicesAged and Disabled Waiver4/1/21RESPONSIBILITY AGREEMENT ADAPTED VERSION Member Name Case ManagerDateRNI, (insert member name), and (insert CM agency and/or PA agency) have

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How to fill out department use only agreement

01

Obtain a copy of the department use only agreement form from the appropriate department or office.

02

Fill out the form completely, making sure to provide all required information such as department name, contact person, purpose of use, and any restrictions or limitations on use.

03

Review the form for accuracy and completeness before submitting it.

04

Sign and date the form where indicated to certify that the information provided is true and accurate.

05

Submit the completed form to the designated department or office for approval and processing.

Who needs department use only agreement?

01

Employees who need to access or use department-specific resources or information that are restricted for internal use only.

02

Contractors or vendors who require access to department resources or information for a specific project or task.

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What is department use only agreement?

Department use only agreement is a document that ensures certain confidential information within a department is used only for authorized purposes.

Who is required to file department use only agreement?

Employees who have access to confidential data within a department are required to file department use only agreement.

How to fill out department use only agreement?

Department use only agreement can be filled out by providing personal information, acknowledging confidentiality requirements, and signing the document.

What is the purpose of department use only agreement?

The purpose of department use only agreement is to safeguard confidential information and ensure it is only used for legitimate purposes.

What information must be reported on department use only agreement?

Department use only agreement typically requires reporting of personal details, confidentiality obligations, and signatures.

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