DIVISION OF MEDICAL ASSISTANCE & HEALTH SERVICES

Contact Us Form for MyNJFCHealthData DAR Requests

Thank you for contacting the NJ Division of Medical Assistance and Health Services. Several resources regarding completing the MyNJFCHealthData DAR Request Forms are available here and can answer most frequently asked questions. Please take a look as the resources may answer your concern.

If you need help, please complete the Contact Us Form below and allow time for review and follow-up as appropriate. Please note that this form should not be used for sending confidential information. Fields marked with an asterisk (*) are required.

First Name:

Last Name:

Email Address:

Confirm Email Address:

Phone Number: Please include a telephone number if you would prefer outreach by phone.

Confirmation ID: Please enter the confirmation ID if you have already submitted a MyNJFCHealthData DAR Request Form or Revocation Form.

Subject: I need help with the following (select all that apply)

--Select all--

Completing MyNJFCHealthData DAR Request Form

Completing Revocation Form

Submitting documents

Status of my request

A technical question

Other

Describe your issue:

The information provided here will be used to contact MyNJFCHealthData Team by email. Please note that this information may be subject to release under the New Jersey Open Public Records Act (OPRA). Please do not submit confidential information.

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DHS-DMAHS-004:MyNJFCHealthData DAR Contact Us

DIVISION OF MEDICAL ASSISTANCE & HEALTH SERVICES

Contact Us Form for MyNJFCHealthData DAR Requests