:uu\)7\r=QDvk*BW)/P -1036/R 4/StmF/StdCF/StrF/StdCF/U(3mo$7Dw )/V 4>> endobj 69 0 obj <>>> endobj 70 0 obj <> endobj 71 0 obj <>/Font<>/ProcSet[/PDF/Text]>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 72 0 obj <>/Subtype/Form/Type/XObject>>stream There are times when we can share confidential client data without the client's permission: To learn more about when it is permissible to share client information please refer to DSHS Administrative Policy 5.02, Section D;4. n3kGz=[==B0FX'+tG,}/Hh8mW2p[AiAN#8$X?AKHI{!7. When to require the DSHS 14-012 (x) consent form. Al hacer clic en el botn Aceptar, acepta el uso de estas tecnologas y el procesamiento de tus datos para estos propsitos. p()md). HR(PD" Completing the DSHS 14-532 AREP form isn't required if the clientis confirming or making changes to their current AREP. Generally, only a patient may authorize release of his/her medical information. csf 14 authorization for release of information authorized representative. endstream endobj 234 0 obj <> stream Please refer to the Payees on Benefit Issuances - Authorized Representatives chapter, WAC 388-460-0005 through 460-0015 for AREP rules specific to the Basic Food (SNAP) program. Case number (optional) Date . DATE . endstream endobj 891 0 obj <>/Subtype/Form/Type/XObject>> stream apes chapter 4 quizlet multiple choice. Hln0z;PJkK"D6~9)a'Gf4OcH|.jDry6vn[U)}SpwS[ MCED Forms Spanish - California csf 14 authorization for release of information authorized representative Forms By Name | A - California 14-532 Authorized Representative Author: Brombacher, Millie A. Choose My Signature. C-761 Bay Area Consortium CAPI Transmittal, 50-85A Language Preference Form Cover Sheet (multi-language), 50-85 Language Preference Form (multi-language), C-134 Cash Assistance Program for Immigrants (CAPI) General Eligibility Information, Payment Levels and Reporting Responsibilities, 20-02 You May Be Required to Apply for SSI, SSP 14 Authorization for Reimbursement of Interim AssistanceChinese,Spanish, SOC 453 CAPI Statement of Household Expenses and ContributionsChinese,Spanish, SOC 455 CAPI State Interim Assistance Reimbursement AuthorizationChinese, Spanish, SOC 809 CAPI Indigence Exception StatementChinese, Spanish. Hj`@ A PDF AUTHORIZED REPRESENTATIVE - California Department of Social Services xc``a``b```a@@1CD'{> %k( El asesor que se le asignar tendr una comunicacin directa desde el principio hasta el final de su gestin y entrega. CHECK ONE Patient Parent Domestic I appoint this individual _____ / _____ Name of individual Name of organization . Medical professionals, financing agents, employers, and even faculty members need to submit a ReleaseAuthorization Formto allow themselves toaccess the information of a particular person. endstream endobj 962 0 obj <>/Metadata 32 0 R/Pages 959 0 R/StructTreeRoot 67 0 R/Type/Catalog/ViewerPreferences<>>> endobj 963 0 obj <>/MediaBox[0 0 612 792]/Parent 959 0 R/Resources 986 0 R/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 964 0 obj <>stream 0 CDSS forms and publications are available only in Portable Document Format (PDF). CF 31 (4/15) - CalFresh Supplemental Form For Special Medical Deductions. csf 14 authorization for release of information authorized representative wG xR^[ochg`>b$*~ :Eb~,m,-,Y*6X[F=3Y~d tizf6~`{v.Ng#{}}jc1X6fm;'_9 r:8q:O:8uJqnv=MmR 4 An AREP assists the client with the application, recertification, and general eligibility processes. csf 14 authorization for release of information authorized representative. endstream endobj 893 0 obj <>/Subtype/Form/Type/XObject>> stream June 29, 2022; creative careers quiz; fSZHti>DB6O,? The DSHS 14-012(x) consent form is a Health Insurance Portability and Accountability Act (HIPAA) compliant form designed for use by the client to authorize an exchange of information outside of basic eligibility information shared with an AREP. endstream endobj 897 0 obj <> stream endstream endobj 895 0 obj <>/Subtype/Form/Type/XObject>> stream How to identify and code an AREP in our automated systems. Printable Forms. 269 0 obj <>stream Authorized Representative - Food, Cash and Medical Benefit Issuances endstream endobj startxref 0 %%EOF 887 0 obj <>/Metadata 39 0 R/PageLayout/OneColumn/Pages 67 0 R/StructTreeRoot 74 0 R/Type/Catalog/ViewerPreferences<>>> endobj 934 0 obj <> stream csf 14 authorization for release of information authorized representative. as my authorized representative to accompany, assist, and represent me in my application for, or . Forms and Brochures - California Department of Social Services When it's permissible to share information without consent. H\Mj0>37"),CFq}0 Building partnerships and connections through outreach, giving, and volunteering. I understand that I may receive a copy of this authorization. The AREP information shall be reviewed at recertification. FREE 15+ Sample Release Authorization Forms in PDF | MS Word | Excel they receive. The name, address, contact numbers, and date of birth are the common information found on this section.