Form EARC-1 "Information Security Representative (Isr) Request Form" - New Jersey

What Is Form EARC-1?

This is a legal form that was released by the New Jersey Department of Human Services - 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 July 1, 2019;
  • The latest edition provided by the New Jersey Department of Human Services;
  • 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 fillable version of Form EARC-1 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Human Services.

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Download Form EARC-1 "Information Security Representative (Isr) Request Form" - New Jersey

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New Jersey Department of Human Services
Division of Aging Services
INFORMATION SECURITY REPRESENTATIVE (ISR) REQUEST FORM
Acute Care Provider EARC Users
:
BRANCH/LOCATION:
INFORMATION SECURITY REPRESENTATIVE (ISR) PROFILE
PRIMARY ISR
ISR NAME:
WORK E-MAIL:
WORK ADDRESS:
WORK PHONE:
SIGNATURE:
By signing, you agree to follow the ISR Responsibilities outlined on pg. 2 of this form.
SECONDARY ISR
ISR NAME:
WORK E-MAIL:
WORK ADDRESS:
WORK PHONE:
SIGNATURE:
By signing, you agree to follow the ISR Responsibilities outlined on pg. 2 of this form.
As the Director/Manager of the organization and employee above, I appoint the aforementioned staff as ISR.
PRINT NAME:
TITLE:
SIGNATURE:
DATE:
Return to: EARCRegistration@dhs.state.nj.us
Division of Aging Services
Or
Office of Community Choice Options
Or
PO Bo x 807
Trenton, NJ 08625-0807
Phone: 609-588-6675
1
EARC-1
JUL-2019
New Jersey Department of Human Services
Division of Aging Services
INFORMATION SECURITY REPRESENTATIVE (ISR) REQUEST FORM
Acute Care Provider EARC Users
:
BRANCH/LOCATION:
INFORMATION SECURITY REPRESENTATIVE (ISR) PROFILE
PRIMARY ISR
ISR NAME:
WORK E-MAIL:
WORK ADDRESS:
WORK PHONE:
SIGNATURE:
By signing, you agree to follow the ISR Responsibilities outlined on pg. 2 of this form.
SECONDARY ISR
ISR NAME:
WORK E-MAIL:
WORK ADDRESS:
WORK PHONE:
SIGNATURE:
By signing, you agree to follow the ISR Responsibilities outlined on pg. 2 of this form.
As the Director/Manager of the organization and employee above, I appoint the aforementioned staff as ISR.
PRINT NAME:
TITLE:
SIGNATURE:
DATE:
Return to: EARCRegistration@dhs.state.nj.us
Division of Aging Services
Or
Office of Community Choice Options
Or
PO Bo x 807
Trenton, NJ 08625-0807
Phone: 609-588-6675
1
EARC-1
JUL-2019
Information Security Representative (ISR) Responsibilities
Each provider must have an ISR on file with the Division of Aging Services (DoAS). The
provider must submit the ISR Request Form and list the individual(s) who will fulfill the duties
of an ISR.
The ISR must be a third person, different from the EARC User and EARC Supervisor.
The ISR is a designated individual within the provider’s organization who shall verify (1) the User
works for the provider listed on this application, and (2) the User needs the access being
requested.
The ISR shall notify DoAS when any of the following occurs:
• A User leaves the provider’s organization.
• A User no longer needs access to the EARC Portal due to any change in the
User’s job duties.
• A User is assigned to a different supervisor. (Submit a new ISR Request Form.)
• An improper disclosure of consumer/applicant protected health information or other personal
information. In such case, notify DoAS immediately at 609-588-6675.
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EARC-1
JUL-2019
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