New Jersey Department of Health

Hospital Financial Reporting and Support

NON-CONFIDENTIAL RELEASE

Conditions for release of the New Jersey data files by Hospital Financial Reporting and Support:

I,	, representing
am requesting the UB-92 non-confidential year-to-date data files for the years

from NJDOH Hospital Financial Reporting and Support.
I agree that these files will be in the custody and maintained by

and will not be released to any other organization
or individual without the prior written approval of NJDOH Hospital Financial Reporting and Support. I further agree that no attempt will be made to identify specific patients or physicians whose records are included in these files, or link information from any other source to records for specific patients or physicians.

No listing of information from individual records will be published or otherwise released by the holder of these files.

I understand that any violation of the above conditions may result in prosecution under all relevant State and Federal Laws.

Representative of
(Date)
Representative of Hospital Financial Reporting and Support
(Date)

HCQO-16

AUG 12

HCQO-16, Non-Confidential Release

Health care quality and oversight, hospital financial reporting and support

EWhite

2004-08-09

NJDOH