Irm Details

Form IRM 15 is a form that can be used to request an installment agreement with the Internal Revenue Service (IRS). The form can be used by individuals or businesses that owe taxes and want to pay them over time. There are several different types of installment agreements available, so it's important to choose the one that best meets your needs. This form can also be used to request a change in an existing installment agreement. Read on for more information about how to use Form IRM 15.

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QuestionAnswer
Form NameForm Irm 15
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
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NEW YORK STATE

OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES

OASAS EXTERNAL USER ACCESS REQUEST

PART A – TO BE COMPLETED BY THE PERSON TO BE GIVEN ACCESS – Please Print Clearly To Avoid Delays in Processing the

Form. Accurate Logons are Dependent Upon the Clear Spelling of the User's Name.

1. NAME OF PERSON TO HAVE ACCESS

Last Name

First

Security I.D. (e.g. Mother’s Maiden Name or other keyword)

Work E-Mail Address

 

 

MI

I understand that OASAS systems contain confidential data, use of which is restricted by and subject to the regulations of Title 42 of the Code of Federal Regulations, 42 CFR Part 2, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) 45 CFR Pts. 160 and 164; the Federal Driver’s Privacy Protection Act (DPPA), 18 USC § 2721; and the NYS Information Security Breach and Notification Act, Chapter 442 and 491 of the Laws of 2005, codified in § 208 of the State Technology Law (STL) and § 899-aa of the General Business Law (GBL); I agree to comply with all requirements set forth within the aforementioned sections of law governing the use and re-disclosure of information obtained through my access to OASAS systems; I also agree that I will neither share my access code with any other person nor share with any unauthorized person information obtained from these systems. My use of information obtained through OASAS systems is solely in accordance with my normal course of business and in connection with the purpose for which my access to these systems has been approved. Misuse and abuse of information that is obtained from OASAS systems will result in a termination of access and may subject me to civil and/or criminal penalties.

User

 

Telephone

 

 

 

Signature

 

No.

(

)

Date

2.AGENCY REQUESTING ACCESS (Select and Complete One Choice Only)

Service Provider Name

OASAS Provider No. (OASAS Certified Only)

LGU / County Name

3.ADDRESS (Street, City, State, Zip Code)

County Code

4. SYSTEM TO BE ACCESSED (See Descriptions on Page 2)

Client Management

Workscope/Objective Attainment (WPR)

Gambling

Provider Directory System

Strengthening Treatment Access and Retention – Quality Improvement (STAR-QI)

Impaired Driver System

Impaired Driver Classroom

County Planning System

Other (specify)________________________

5. OPTIONS/LEVELS OF ACCESS

 

Providers

 

 

LGU

OTHER

On-Line Reporting Options:

 

 

 

 

 

Data Entry or

File Transfer or

Inquiry

Inquiry

 

Data Entry

or

Inquiry

 

 

Data Entry

 

Data Entry

or

Inquiry

 

 

 

 

Data Entry

 

 

 

 

 

 

 

Data Entry

or

Inquiry

 

 

Inquiry

 

Program Number:

 

 

 

 

 

 

 

 

 

 

 

Clinical Data Entry or

Clinical Inquiry

or

 

DMV Inquiry

DDP Data Entry

or

DDP Inquiry

 

 

 

 

 

 

 

 

 

 

 

 

DMV Data Entry

DDP Data Entry or

DDP Inquiry

 

 

 

or

 

 

 

 

 

 

 

DMV Inquiry

Data Entry

or

Inquiry

 

 

Inquiry

N/A (e.g. Training

 

 

Catalog)

 

 

 

 

 

 

 

PART B – TO BE COMPLETED BY THE AGENCY CONTACT PERSON AND SENT DIRECTLY TO OASAS AS INSTRUCTED ON PAGE 2

 

NAME OF AGENCY CONTACT PERSON (Print Last, First, MI)

Telephone No.

Fax No.

 

 

(

)

(

)

 

 

 

 

 

 

WORK E-MAIL ADDRESS

I hereby authorize the employee identified in Part A to obtain access to the system indicated in conjunction with his/her official duties. I will contact OASAS immediately when the individual no longer requires such access.

____________________________________________________

 

_______

 

______

 

 

 

 

Signature

 

 

 

 

 

 

Date

 

 

 

 

FOR USE BY BUREAU OF INFORMATION TECHNOLOGY SERVICES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOG-ON

USER NO.

 

SYSTEM ACCOUNT

APPLICATION ACCESS

 

USER NOTIFIED

 

 

 

 

 

ADDED

GRANTED

 

 

 

 

 

 

 

 

 

________

________

________

________

 

________

________

 

 

 

 

 

Initials

Date

Initials

Date

 

Initials

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDITIONAL COMMENTS/INSTRUCTIONS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REFER ANY QUESTIONS TO OASAS HELP DESK AT (518) 485-2379

 

 

 

IRM -15 (Rev 3/13)

 

 

 

 

 

 

 

 

 

 

INFORMATION AND INSTRUCTIONS

PURPOSE

The purpose of this form is to provide a means for agencies (services providers, Local Governmental Units [LGUs] and other authorized agencies) to arrange for their staff to obtain access to a variety of on-line data systems maintained by OASAS in order to process data associated with these systems electronically.

PROCESSING THE ACCESS REQUESTS

Step 1 - The person for which access is being requested completes Part A (Sections 1-4), including the security ID (his/her mother’s maiden name or other keyword) which will be used for security purposes, and identifying information by which they can be contacted (telephone number, fax number and e-mail address).

Department of Motor Vehicles employees who work at county DMV office locations indicate county office in the LGU / County Name, e.g. DMV Albany County. All other DMV employees enter DMV Central Office in the Service Provider Name.

The systems to be accessed (described below) should be selected, including the appropriate processing option under which data will be processed and the appropriate level of access, consistent with the tasks to be performed.

The individual signs the form agreeing that he/she will abide by the system’s users requirements.

Step 2 - The agency contact person reviews the information completed in Part A verifying that the appropriate access is being requested and completes Part B authorizing such access and providing identifying information by which they can be contacted (telephone number and email address) and mails the form directly to:

NYS OASAS

1450 Western Avenue

Albany, NY, 12203-3526

Attention: HELP DESK

or faxes the form to:

(518) 457-2387 – Attention: HELP DESK

(please do not fax information & instruction pages)

OASAS will contact the individual directly to provide a confidential access code and instructions on establishing an individual password.

DESCRIPTIONS OF SYSTEMS TO BE ACCESSED

Client Management System - enables providers of treatment services to report client demographic and service delivery data on- line. This includes data on admissions, discharges, transfers, service delivery data, including units of service, and waiting list data. The system can accept inquiries and generate operational and statistical reports. The system is accessible by service providers and associated LGU administrators.

Workscope/Objective Attainment System - enables providers of funded treatment services to view quarterly performance data and related reports based on Workscope mandatory objective performance targets identified for various performance indices for their programs.

Gambling System – enables providers of gambling treatment services to report demographic and service delivery data on-line. This includes data on admissions, discharges, service delivery data, including units of service and waiting list data. The system can accept inquiries and generate operational and statistical reports. The system is accessible by service providers and associated LGU administrators.

Provider Directory System – enables providers (treatment, prevention, LGU) to maintain their contact information and limited information regarding their provider and programs.

Strengthening Treatment Access and Retention – Quality Improvement (STAR–QI) – helps treatment providers become more efficient in processing their clients by tracking key indicators from the first request for service through the first month of treatment. STAR-QI is a combination of the Strengthening Treatment Access and Retention – State Infrastructure (STAR – SI) and Network for Improving Addiction Treatment (NIATx) initiatives.

Impaired Driver System – enables providers of clinical services to impaired driving offenders and Drinking Driver Program (DDP) services to report client service delivery information on-line for motorists arrested for or convicted of impaired driving related offenses pursuant to section 1192 of the Vehicle and Traffic Law. Data collected via this system will be shared with the Department of Motor Vehicles (DMV) as required for their relicensing process.

Impaired Driver Classroom – enables county DMV employees to enroll eligible motorists in New York State DDPs. Approved NYS DDPs will access the system to view rosters online, transfer or reschedule motorists to other classes as necessary, and enter information regarding instructors and class locations. Central Office DMV employees will access the system for the purpose of identifying approved DDP locations and instructors.

County Planning System – is a Web-based application that was developed as a cost-effective and efficient means for completing and submitting required annual planning forms, communicating with the field on planning-related matters, and providing timelier and more accessible data resources.

SECURITY FEATURES

To assist the user in managing their password, the assignment of a “hint” is provided. The use of the “hint” allows the user to assign a new password if they have forgotten their current one. This “self management” feature is available via the Change Password link on the OASAS Applications login page.

If an incorrect login or password is used to access an OASAS system, the account will be disabled after five consecutive attempts. Access rights will only be restored by contacting the OASAS Help Desk. Please note the login and password are case sensitive.

If a user does not access an OASAS system during a consecutive 90 day period, the account will be disabled. Access rights will only be restored by contacting the OASAS Help Desk.

If a user does not access an OASAS system during a consecutive 400 day period, the account will be closed and access rights terminated. Access rights will only be restored by resubmitting a new IRM-15 request.

IRM -15 (Rev 3/13)

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