Standardized Board Resolution Form - DHS Department of Human Services Policy Circular

Sep 2, 2026

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Standardize the content of Provider Agency Board Resolutions across all Department of Human Services (DHS) Departmental Components to ensure required obligations are identified and committed. The circular applies to DHS Third Party contracted Provider Agencies, universities/colleges, and for-profit organizations. It specifies completion of Attachments I and II, triggers new resolutions within 10 business days after content-changing changes, and requires submission as part of the contract package, referencing Policy Circular P1.01.

LanguageEnglish

CategoryForms

FormatDOCX

Pages4

Reading Time2 min

AccessFree to download

Purpose

Scope

Policy

Completion, Updating and Submission

Standardized Board Resolution

HIPAA Commitment Options

Legal Advice

Supporting Information and Certification

State of New Jersey Department of Human Services SUBJECT: Standardized Board Resolution Form EFFECTIVE: This policy shall become effective August 1, 2009. PROMULGATED: July 20, 2009 SUPERCEDES: Standardized Board Resolution Form, promulgated November 21, 2007 PURPOSE: The purpose of this policy circular is to standardize the content of the Provider Agency Board Resolutions across all Department of Human Services (DHS) Departmental Components to assure that all of the required obligations are identified and committed to by the Provider Agency Board. SCOPE This policy circular applies to all DHS Third Party incorporated contracted Provider Agencies, Universities/Colleges and for-profit organizations. II. POLICY Periodically Boards of Directors in conducting the business of their organizations attest to their actions or decisions by way of written resolutions. The DHS requires Contract Providers to complete and file the attached standard board resolution when executing a DHS Third Party Social Service Contract. Requirements for completion, updating and submission The Attachment I, Page 1 is to be completed by the Agency and the same for Attachment II. When any changes occur which would affect the contents of the form, the Board is to convene and complete a new Board Resolution and submit it to the Departmental Component within 10 business days of the change unless otherwise specified in the DHS policy. The completed form is to be returned to the Departmental Component with all other required contract documents as part of the contract package. (See Policy Circular P1.01, Documents and Conditions Required for Processing, Executing and Documenting a DHS Third Party Contract.) Issued by: Chief of Staff Department of Human Services STANDARDIZED BOARD RESOLUTION The Board endorses the following commitments as defined in this document: Health Insurance Portability and Accountability Act (HIPAA)* Specific to HIPAA (Health Insurance Portability and Accountability Act), the above noted Provider Agency is either (check A or B): ___ A) a covered entity (as defined in 45 CFR 160.103) ___ B) a non-covered entity and has executed a DHS Business Associate Agreement (BAA) last dated ________. ___ C) a non-covered entity that will not be receiving or sharing personal health information. Once executed, the BAA will be included in the Departmental Component’s official contract file. The BAA will be considered applicable indefinitely unless there is a change in the Provider Agency’s status, information or the content of the BAA, in which case it is the responsibility of the contracted Provider Agency to revise the BAA. The Board agrees that if there is any change in their BAA Status the Departmental Component will be immediately notified and the appropriate information provided within 10 business days. * This section is not applicable for DCF Office of Education Contracts. Legal Advice The Board acknowledges that the Department of Human Services does not and will not provide legal advice regarding the contract or about any facet of the relationship between the Department of Human Services and the Provider Agency. The Board further acknowledges that any and all legal advice must be sought from the Provider Agency's own attorneys and not from the Department of Human Services. Page 1 of 1 DEPARTMENT OF HUMAN SERVICES (DHS) Standardized Board Resolution Form Supporting Information for Contract # _______________ for Contract Period _________________________ to ______________________________. Agency: ___________________________________________________________ Certification: We certify that the information contained in, or included with, this contract document is accurate and complete. __________________________________ __________________________ Chairperson, Board of Directors Date __________________________________ ___________________________ Executive Director Date Authorized Signatories for Contract documents, check

FAQs

Who must complete and submit the standardized board resolution form?

All DHS Third Party incorporated contracted Provider Agencies, universities/colleges, and for-profit organizations must complete and file the attached standard board resolution when executing a DHS Third Party Social Service Contract.

What must be done when changes affect the form’s contents?

The Board must convene and complete a new Board Resolution, then submit it to the relevant Departmental Component within 10 business days of the change unless DHS policy specifies otherwise.

What HIPAA commitment options can the Provider Agency Board endorse?

The Provider Agency must indicate whether it is a covered entity, a non-covered entity that has executed a DHS Business Associate Agreement (BAA), or a non-covered entity that will not receive or share personal health information.

Sep 2, 2026

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