Form FHS-19 "Agreement Reached Withdraw of Dispute Resolution Request" - New Jersey

What Is Form FHS-19?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2012;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form FHS-19 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form FHS-19 "Agreement Reached Withdraw of Dispute Resolution Request" - New Jersey

Download PDF

Fill PDF online

Rate (4.3 / 5) 20 votes
New Jersey Department of Health
Early Intervention System
P. O. Box 364
Trenton, NJ 08625-0364
AGREEMENT REACHED
WITHDRAW OF DISPUTE RESOLUTION REQUEST
Name of Individual/Organization Filing Complaint
Date
Participating Agency/Provider Complaint Filed Against
Nature of Complaint
Steps Agreed To
I have reviewed and discussed the above information with
.
I feel that adequate steps have been agreed upon that address my concern(s). Therefore, I am withdrawing my
formal complaint at this time.
I understand that I may, at any time, re-file this complaint should the agreed upon steps not be carried out, if I am
dissatisfied with the results or for any other reason. I also understand that I may file a complaint on other matters
related to provision of early intervention services. I have received a copy of the “New Jersey Early Intervention
System Family Rights.” These rights have been explained to me and I understand them.
Signature of Parent
Date
Agency/Provider agrees to implement/complete the steps contained in this agreement.
Signature of Procedural Safeguards Coordinator/Designee
Date
FHS-19
SEP 12
New Jersey Department of Health
Early Intervention System
P. O. Box 364
Trenton, NJ 08625-0364
AGREEMENT REACHED
WITHDRAW OF DISPUTE RESOLUTION REQUEST
Name of Individual/Organization Filing Complaint
Date
Participating Agency/Provider Complaint Filed Against
Nature of Complaint
Steps Agreed To
I have reviewed and discussed the above information with
.
I feel that adequate steps have been agreed upon that address my concern(s). Therefore, I am withdrawing my
formal complaint at this time.
I understand that I may, at any time, re-file this complaint should the agreed upon steps not be carried out, if I am
dissatisfied with the results or for any other reason. I also understand that I may file a complaint on other matters
related to provision of early intervention services. I have received a copy of the “New Jersey Early Intervention
System Family Rights.” These rights have been explained to me and I understand them.
Signature of Parent
Date
Agency/Provider agrees to implement/complete the steps contained in this agreement.
Signature of Procedural Safeguards Coordinator/Designee
Date
FHS-19
SEP 12