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Form 470 3767-2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the 'Name of Facility or Agency' in the designated field. Ensure that the name is accurate and matches your official records.
- Next, input the 'Billing Account Number' as provided by DCI upon approval of your SING account. This number is crucial for processing your request.
- In the section labeled 'Administrator', type or print the name of the administrator responsible for signing this agreement. This ensures accountability within your agency.
- Finally, have the administrator sign in the designated area. This signature confirms that your agency agrees to abide by all legal provisions regarding child and dependent adult abuse information.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2016 | 4.7 Satisfied (183 Votes) |
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Related links
Feb 9, 2015 Please note. Any information in this document is subject to change without notice and does not represent a commitment.Read more
Form 470-3767 shall be signed by the administrator of the health care program and be sent to the central registry before receipt of the information from theRead more
The administrator of the agency or facility must sign a copy of this Access to Confidential. Abuse Information and Non-Redissemination Agreement (form 470-3767)Read more