csf 14 authorization for release of information authorized representative

Educational Institutions. 05/2018 CFSA - Authorization to Access and Disclose Mental Health or Substance Abuse Information Page 1 of 2 . H\Pj0+t=,G([ @ $0X + Appointment of Authorized Representative 1 . V)gB0iW8#8w8_QQj@&A)/g>'K t;\ $FZUn(4T%)0C&Zi8bxEB;PAom?W= El asesor que se le asignar tendr una comunicacin directa desde el principio hasta el final de su gestin y entrega.La persona asignada para el proceso de Apostilla en los distintos Ministerios, Cmaras, Colegios y Organismo Oficiales que requiera, con ms de 20 aos de experiencia Contamos tambin con traductores Jurados reconocidos por el Ministerio de Asuntos Exteriores, Nuestro personal est altamente cualificado. calfresh forms csf 14 authorized representative calfresh calfresh proof of income . Generally, only a patient may authorize release of his/her medical information. "F$H:R!zFQd?r9\A&GrQhE]a4zBgE#H *B=0HIpp0MxJ$D1D, VKYdE"EI2EBGt4MzNr!YK ?%_&#(0J:EAiQ(()WT6U@P+!~mDe!hh/']B/?a0nhF!X8kc&5S6lIa2cKMA!E#dV(kel }}Cq9 9A~c+e!0Ow ;3`yKn:nSL5)@~rMBEr~u8pAYh="4e3&X\6H(Tzzop|kUM.Mwcfe FKJj6 B^v %%EOF 0. Gathering information is vital for every type of transaction in any organization. I understand that if I do not check any of the boxes below, my authorized representative will be authorized to perform all of the . Notice to Terminating Employees. csf 14 authorization for release of information authorized representative. CHECK ONE Patient Parent Domestic The 14-012(x) is the correct form for authorizing the sharing of specified confidential information between specified parties for a specified period of time. lx}I=u1\=VrN!F\UlRpDRhO|#s9c^l~3e;12qCqB*.3P-J=*S=+OeD^_ ,rZ SIGNATURE . To order forms, complete the form at the bottom of this page. csf 14 authorization for release of information authorized representative. 2. "J@B+$)5@h(-4:H.HHr=0ZP2,Ea qt)4/F.z EMC Name . endstream endobj startxref Authorization Forms are common in the medical industry, especially if a patient is under a healthcare providers benefits. HyTSwoc [5laQIBHADED2mtFOE.c}088GNg9w '0 Jb Notable exceptions to the rule are as follows: a. information without appointing an AR using a written authorization, such as a "Release of Information" form, or a telephonic authorization. 4pIe^8 /;$GOj^y%^.N.ycq:9;dRs);a;I&,d0m2.erHe9eeMiB z 4K[}{5hp~8S=P8 ngB[pNrP-=*|?p0;n%]5KY{ Hj`@ A 0 endstream endobj 228 0 obj <> stream Authorized Representatives for hearing purposes pursuant to . . x- [ 0}y)7ta>jT7@t`q2&6ZL?_yxg)zLU*uSkSeO4?c. R -25 S>Vd`rn~Y&+`;A4 A9 =-tl`;~p Gp| [`L` "AYA+Cb(R, *T2B- Check the AREP information coded in ACES at each review. endstream endobj 896 0 obj <>/Subtype/Form/Type/XObject>> stream Create your signature and click Ok. Press Done. hbbd```b``N?9d fHz0iL"``,~H2jU'@d!H#Yh? %PDF-1.6 % The client can identify an AREP on the application, eligibility review form, or DSHS 14-532 authorized representative form. Hln0z;PJkK"D6~9)a'Gf4OcH|.jDry6vn[U)}SpwS[ The Alameda County Social Services Agency provides resources and opportunities in a culturally responsive manner to enhance the quality of life in our community by protecting, educating, and empowering individuals and families. AREPs are not automatically eligible to be an EBT Alternate Card Holder for Basic Food or cash benefits. 16x;ltAx}0 xcbd```b```r5&H2&[k`XW Yq,DH D endstream endobj 73 0 obj <>stream EMC 6m5q'b` HX$a c @55| /MS9 Follow the step-by-step instructions below to design your cal fresh authorized representative form: Select the document you want to sign and click Upload. endstream endobj 897 0 obj <> stream hbbd```b``"VH2H&c&d,i &YH%91 DH2.g&"+&{*.a`$:F@ PP they receive. nQt}MA0alSx k&^>0|>_',G! June 29, 2022; creative careers quiz; EMC xcbd```b``V}`r5dXWd +D2)H "0012d[20j?cS&.@~{ h! The patient or legally authorized representative must sign and date the form. %%EOF Or, you may also limit duties. 63-57 CalFresh Application Cover Sheet (multi-language), CW 2223 Demographic QuestionnaireChinese, Spanish, 50-110 Voter Preference FormCambodian, Chinese, Farsi, Spanish, Tagalog,Vietnamese. Quieres probar una bsqueda? A relative of the patient may also use an authorization form under this category especially of the patient is a minor and requires a guardian ad he stays in the medical clinic. EMC illinois obituaries 2020 . If an individual AREP is representing an organization, other individuals from that organization within the same department may also act as an AREP. These forms are in Adobe PDF format and you must have a copy of Adobe Acrobat Reader installed on your system to view them. AD 933 (12/20) - Intercountry Readoption Acknowledgment. PDF fill and print forms may be completed online and printed to hardcopy to be signed and mailed in or submitted in person to an eligibility worker for processing. endstream endobj 892 0 obj <>/Subtype/Form/Type/XObject>> stream /%9TB!:(zQRN The DSHS 17-063 authorization form and the HCA 80-020 authorization for release of information form are HIPAA compliant forms designed for use by the client to authorize the release of existing documents to a specified individual or agency. MC 018 Medi-Cal Information for Applicants (multi-language), POP Parentage Opportunity Program Brochure, GEN 1365 Notice of Language Services (Multi-language), YAE General Information Notice for the Young Adult ExpansionCambodian, Chinese, Farsi, Spanish, Tagalog,Vietnamese, OAE General Information Notice for theOlderAdult ExpansionCambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, MC 003 Medi-Cal Services for Children and Young Adults: EPSDTCambodian, Chinese, Farsi, Spanish, Tagalog, Vietnamese, MC 020 Notice to Beneficiaries Regarding IRS Form 1095-BSpanish, MC 219 Important Information for Persons Requesting Medi-CalCambodian, Chinese, Farsi, Spanish, Tagalog, Vietnamese, MC 372 Breast and Cervical Cancer Treatment Program (BCCTP)Cambodian, Chinese, Farsi, Spanish, Tagalog,Vietnamese, MC 007 Medi-Cal General Property Limitations, DHCS 7077 Notice Regarding Transfer of a Home for both a Married and an Unmarried Applicant/BeneficiarySpanish, DHCS 7077A Notice Regarding Transfer of a Home for both a Married and an Unmarried Applicant/Beneficiary, PUB 13 Your Rights Under California Public Benefits Programs - For People ApplyingForOrReceiving Public AidInCaliforniaCambodian, Chinese, Farsi, Spanish, Tagalog, Vietnamese, PUB 68 My Medi-Cal: How to Get the Health Care You NeedCambodian, Chinese, Farsi, Spanish, Tagalog, Vietnamese, PUB 183 Medical and Dental Health Check-ups CHDP BrochureSpanish, 910169 California Families Grow Healthy with WIC brochureSpanish. %PDF-1.7 % When it's permissible to share information without consent. 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. Esta web utiliza cookies propias y de terceros para su correcto funcionamiento y para fines analticos. 1B114F All Forms N/A Authorization for Release of Information Authorized Representative CSF 14 506481 Reason Code County Category NOA Action Document Name Number Template 300001 Placer Forms Affidavit to N/A Obtain Duplicate Warrant All 662 609763 300001 Santa Barbara Forms N/A Affidavit to Obtain Duplicate of Lost or Log on to your account or contact your county office to update your information. endstream endobj 68 0 obj <>>>/Filter/Standard/Length 128/O(! TO BE COMPLETED BY APPLICANT / BENEFICIARY . Pn?%9:t These forms allow the disclosure of a designated set of records from the individual's DSHS or HCA file. % DSBlank Form . An AREP is not authorized to receive health information about clients unless they have power of attorney or have been named on the completed and signed DSHS 14-012(x) consent form. The records of a students grades and transcript from the previous university will be disclosed with the aid of a Transcript Release Authorization Form. endstream endobj 895 0 obj <>/Subtype/Form/Type/XObject>> stream I appoint this individual _____ / _____ Name of individual Name of organization . D.C. Child and Family Services Agency 200 I Street SE, Washington, DC 20003 (202) 442-6100 www.cfsa.dc.gov Here's How, CW 2166 (11/21) - Multilingual Work Really Pays! 0 Authorized Representative/ HIPAA Form PLEASE PRINT CLEARLY * This information is mandatory. 0,00 . Printable Forms. See WORKER RESPONSIBILITIES. Dental, Request for Access to Protected Health Information. hb```52@(1{yPdVDHl] O_ $8:)HX 2~F^HHi,l,,&@Spo//;Q#!k84#inpu w S*} # _gL7YG{b>v#F>//C1n taqOY__5UUeKZ\Uq2~?&Ymn J?4y/*Eue!~VUYTqZy?6u=gD Nx>mp ((J,8p Fh # @`"PT {5@\jM+| sI Edit your calfresh release of information form online. Here's How, CW 2184 (8/16) - CalWORKS 48-month Time Limit, CW 2184 (4/21) - CalWORKs 60-Month Time Limit, CW 2186A (12/12) - CalWORKs Exemption Request Form, CW 2186A (4/21) - CalWORKs Exemption Request Form, CW 2186B (4/21) - CalWORKs Exemption Determination, CW 2187 (4/11) - Your CalWORKs 48-Month Time Limit, CW 2187 (4/21) - Your CalWORKs 60-Month Time Limit, CW 2188 (4/02) - Verification Of Aid For The Temporary Assistance For Needy Families (TANF) Program, CW 2189 (3/15) - Notice of Your CalWORKs Time Limit - 42th Month On Aid, CW 2189B (9/20) - Notice Of Your CalWORKs Time Limit 57TH Month On Aid (Use Starting May 1, 2022), CW 2190A (4/21) - CalWORKs 60-Month Time Limit Extender Request Form, CW 2190B (5/16) - CalWORKs 48-Month Time Limit Extender Determination Denial Form, CW 2190B (4/21) - CalWORKs 60-Month Time Limit Extender Determination Form, CW 2191 (4/21) - Time On Aid Verification For CalWORKs/TANF 60-Month Time Limits, CW 2192 (4/21) - Tracking Non-California TANF Assistance For Time Limits, CW 2200 (5/22) - Request For Verification, CW 2200LP (6/19) - Request For Verification, CW 2201 (6/09) - Unemployment Insurance Benefits Referral Form, CW 2203 (11/09) - Request For Supplemental Payment By Check Or Direct Deposit, CW 2208 (2/13) - Your Welfare-To-Work 24-Month Time Clock, CW 2209 (12/14) - Immunization Good Cause Request Form, CW 2211 (11/14) - Your CalWORKs Reporting Rules Have Changed, CW 2212 (11/14) - The Rules For Your CalWORKs Case Have Change, CW 2213 (10/15) - Response To Request To Inspect Case Record CalWORKs, CalFresh, TCVAP, And Refugee Programs, CW 2215 (10/20) - California Work Opportunity and Responsibility to Kids (CalWORKs) Important Information for Safety Net And Certain Child-Only Case, CW 2217 (1/15) - CalWORKs Request For Voluntary Repayment, CW 2218 (7/19) - Rights, Responsibilities And Other Important Information For The California Work Opportunity And Responsibility To Kids (CalWORKs) Program (Non-Needy Caretaker Relative With Relative Foster Child), CW 2218 (6/21) - Rights, Responsibilities And Other Important Information For The California Work Opportunity And Responsibility To Kids (CalWORKs) Program (Non-Needy Caretaker Relative With Relative Foster Child), CW 2218 (3/22) - Rights, Responsibilities And Other Important Information For The California Work Opportunity And Responsibility To Kids (CalWORKs) Program (Non-Needy Caretaker Relative With Relative Foster Child), CW 2219 (5/16) - Application For California Work Opportunity And Responsibility To Kids (CalWORKs) (Non-Needy Caretaker Relative With Relative Foster Child), CW 2223 (9/18) - Demographic Questionnaire For CalWORKs, Refugee Cash Assistance (RCA), Entrance Cash Assistance (ECA), Trafficking And Crime Victims Assistance Program (TCVAP) And CalFresh Programs, CW 2224 (6/19) - CalWORKs Home Visiting Initiative (HVI), DFA 377.1A (3/02) - Notice Of Denial Or Pending Status, DFA 377.7A (4/21) - Notice Of Administrative Disqualification, DFA 377.7D2 (10/00) - Food Stamp Repayment Notice for Administrative Errors Only, Final Notice, DFA 377.7E (7/04) - Food Stamp Repayment Agreement For Administrative Errors Only, DFA 377.7F (6/18) - CalFresh Overissuance Notice - Intentional Program Violation (IPV), DFA 377.7F LP (6/18) - CalFresh Overissuance Notice - Intentional Program Violation (IPV), DFA 377.7F1 (10/00) - Food Stamp Repayment Notice for an Intentional Program Violation (IPV) Only, Final Notice, DFA 377.7G (5/02) - Food Stamp Repayment Agreement For An Intentional Program Violation (IPV) Only, DFA 377.10 (6/04) - Food Stamp Notice Of Disqualification, DFA 377.11B (11/00) - Food Stamp Notice Of Continuance, DPA 19 (6/22) - Appointment OfAuthorized Representative, DPA 315 (7/99) - Withdrawal/Conditional Withdrawals Of Request For Hearing, DPA 435 (1/18) - County Allegation Of Intentional Program Violation/Statement Of Position (Request For An Administrative Disqualification Hearing), DPA 436B (8/18) - County Information Letter, DPA 479 (12/17) - Administrative Disqualification Hearing Waiver - CalWORKs/CalFresh, EBT 1232 (6/22) - CalFresh Notice Of Action - EBT Account, EBT 2216 (10/22) - EBT Surcharge Free - Direct Deposit Handout, EBT 2259 (1/23) - Report Of Electronic Theft Of Benefits, EBT 2259A (11/21) - EBT Scamming Acknowledgement, EBT 2260 (8/21) - Excessive Card Replacement Warning Letter, EFA 7 (7/21) - The Emergency Food Assistance Program (TEFAP) Certification Of Eligibility, EFA 7A (BI) (3/11) - Emergency Food Assistance Program (EFAP) Certification Of Eligibility, EFA 14 (3/23) - The Emergency Food Assistance Program (TEFAP) 2023Income Guidelines, EFA 15 (3/23) - Alternate Pick-Up Request Form The Emergency Food Assistance Program (TEFAP) 2023Income Guidelines, FC 2 NM (2/12) - Statement of Facts Supporting Eligibility For AFDC-Extended Foster Care (EFC). %PDF-1.6 % Clients must complete a DSHS 14-532 AREP form when designating a new AREP. The below forms may be dropped at asecure drop box, at one of our offices, during regular business hours, 8:30 a.m. to 5:00 p.m or submitted by fax to 510-670-5095or by mail at P.O. /Tx BMC C. del Doce de Octubre, 24, local 7, 28009 Madrid, Apostillado documentos del Registro Civil, Apostillado documentos para trabajar en el Extranjero, Apostillado de Documentos emitidos en Registro Civil, Apostilla de documentos para trabajar en el Extranjero. By observing a proper authorization process, the confidential information will be kept secured and will only be distributed to the people whose names are stated on the authorization form document. For more information see Confidentiality and Public Disclosure. Legal Guardianship is designated by coding the AREP screen Rep Type field in ACES with the following: Power of Attorney for cash, medical, and basic food is designated by coding the AREP screen Rep Type field in ACES with AD or NA. endstream endobj 229 0 obj <> stream CF 215 (9/14) - CalFresh Notification Of Inter-County Transfer. endstream endobj 890 0 obj <>/Subtype/Form/Type/XObject>> stream %PDF-1.6 % DATE . When to require the DSHS 17-063 authorization form or HCA 80-020 authorization for the release of information form. 2020 (e) (7); 7 C.F.R. Problems with downloading forms? See AREP definition above. Medi-Cal MC 382: Appointment of Authorized Representative Cambodian, Chinese , Farsi, Spanish, Tagalog, Vietnamese MC 383: Authorized Representative Standard Agreement for Organizations. H|n@,SEKlp5i"o93vtEew~iyL7{l4MW_jpymf_y>qli|?O]0w2GlH6tyW?wKYX~bcdo9gL[^KQ (m6 K%%@IX 140 0 obj <> endobj Case number (optional) Date . This chapter defines an authorized representative (AREP) and provides instruction on: What form to use in order to code someone in ACES or the ECR as an AREP. CF 32 (6/13) - CalFresh Request For Contact. AREP designation isn't valid after the certification period. El asesor que se le asignar tendr una comunicacin directa desde el principio hasta el final de su gestin y entrega. Record the representative's name and address on the AREP screen in ACES. Choose My Signature. endstream endobj startxref 166 0 obj <>/Encrypt 141 0 R/Filter/FlateDecode/ID[<7D6D17A302C5ACFD3A69D63CA072DE31><93B97E192985F34987B8D519A2DF3746>]/Index[140 61]/Info 139 0 R/Length 97/Prev 26174/Root 142 0 R/Size 201/Type/XRef/W[1 2 1]>>stream nQt}MA0alSx k&^>0|>_',G! Posted on June 29, 2022 in gabriela rose reagan. pvphVwh h E^z8rn+>m>^#r^n/^_^Nsr#\rLL&I\R&4N8/` _%c Finance and accounting industry. SECTION I. Authorized Representative Address: Authorized Representative Telephone Number: I authorize the above designated individual to act as my representative until I revoke this authorization for the purposes checked below. endstream endobj 235 0 obj <. The Information to be Released. This form is used to document the designation of an Authorized Representative for a consumer. %=coF5H_}{AWwEPY]1BE8=mF~tU3PI3=^mdHCgIsME>5s4Y|hhBo(cHivU.-KGr0h_i9R .r>&S6h. "F$H:R!zFQd?r9\A&GrQhE]a4zBgE#H *B=0HIpp0MxJ$D1D, VKYdE"EI2EBGt4MzNr!YK ?%_&#(0J:EAiQ(()WT6U@P+!~mDe!hh/']B/?a0nhF!X8kc&5S6lIa2cKMA!E#dV(kel }}Cq9 AD 4320 (6/22) - Adoption Assistance Program (AAP) Agreement . AnEmployment Authorization Formshould be signed by the employee to allow the employer in viewing his information and do a reference check from his previous company. as my authorized representative to accompany, assist, and represent me in my application for, or . The Authorizing Individual. Medi-Cal Eligibility Divisi on forms are listed below, alphabetically, by form number and has been translated into Spanish. hXmo6+aD"@/@-}p-nQ[qduyG1xa_Q"F)|+Nxb4Fl,S`# 985 0 obj <>/Filter/FlateDecode/ID[]/Index[961 74]/Info 960 0 R/Length 119/Prev 397332/Root 962 0 R/Size 1035/Type/XRef/W[1 3 1]>>stream . endstream endobj startxref 0 %%EOF 223 0 obj <>/Metadata 5 0 R/PageLabels 220 0 R/Pages 6 0 R/StructTreeRoot 17 0 R/Type/Catalog/ViewerPreferences<>>> endobj 289 0 obj <> stream 273.2 (n) (1); MPP 63-402.61; ACL 19-55 .] Photocopies of this authorization shall be considered as valid as an original. xc``a``b```a@@1CD'{> %k( Title 22 of the . /Tx BMC How to identify and code an AREP in our automated systems. E' p ?564'>nn;XU|YEnZ=[{1"if$@XN=>kJU:pJA^ ?3[p$~at:T4{:n1}j 3w q.m,IU:h#BcQ~)U!!W"Y6Gt Zs2v-Sz :n7c+@1EbPCM,y~~YH?z&x1oo (:~ g/^v;]OZI\f(BqJlB7hK~$ Rv bZ}uz@pv_0Q H / hbbd``b`f@@2{ V)gB0iW8#8w8_QQj@&A)/g>'K t;\ $FZUn(4T%)0C&Zi8bxEB;PAom?W= Clients should make an initial designation of an AREP on the application, review, or DSHS 14-532 AREP form. 3013d100Hh>pY^?)~|P- 9& A(pQ!R(PRBEe8R$d,J8JNM6-q NOTE: Some links on this page are documents in Adobe . its regulations and We help individuals, families, and communities access services and public benefits that make a difference in their lives. hb```"oV)af`0p &I0nafX4AD?P`YJD!NMV$2F3{i1 032p040060`}Pht@/ABo].T.`FY?R~04\.zd'&?Jl| @ H/M An authorized representative is a non-household member who can apply for benefits, complete work registration forms, complete required reporting or use the Electronic Benefits Card to purchase the household's food. endstream endobj startxref 0 %%EOF 887 0 obj <>/Metadata 39 0 R/PageLayout/OneColumn/Pages 67 0 R/StructTreeRoot 74 0 R/Type/Catalog/ViewerPreferences<>>> endobj 934 0 obj <> stream Don't addthe new AREP untilwe receive: a signed Eligibility Review form with completed AREP section. N')].uJr 77 0 obj <>/Encrypt 68 0 R/Filter/FlateDecode/ID[<7505846DAAB7146F6DCE917783904669><3A94F331270E8948AED6D6D48DFB54A6>]/Index[67 36]/Info 66 0 R/Length 64/Prev 84923/Root 69 0 R/Size 103/Type/XRef/W[1 2 1]>>stream The following need to be completed during the CAPI application process. 14-532 Authorized Representative Author: Brombacher, Millie A. Form processing may be delayed if fields with an asterisk are not filled out. Delete coded AREP information if you can'tconfirm with the client that it's still valid. /Tx BMC There are times when we can share confidential client data without the client's permission: To learn more about when it is permissible to share client information please refer to DSHS Administrative Policy 5.02, Section D;4. An AREP can share any information relevant to eligibility; however, the department can only share information with the AREP that is necessary for the purposes of determining financial eligibility. Tn+P6z! ^.K(uA_D6}\9P(|$I'1'O+bJ+RWL^3UT`>S)mbb6JF)P }3$@JAt " ]YL /@ > 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. /Tx BMC Document extensions or changes to the designated AREP in ACES. The following forms need to be completed during the application process. Quality Assurance Fee Program. 234 0 obj <> endobj /Tx BMC 961 0 obj <> endobj /Tx BMC Appointment of Representative (MC 306, 06/07) Alt: Spanish (01/08) Authorization for Release of Information (Large Print) (MC 220 14pt, 04/08) Alt: Spanish; Authorization for Release of Information (MC 220 8pt, 06/08) csf 14 authorization for release of information authorized representative. csf 14 authorization for release of information authorized representative. HyTSwoc [5laQIBHADED2mtFOE.c}088GNg9w '0 Jb 257 0 obj <>/Filter/FlateDecode/ID[<2C3F7BAF13469A49B4F374642767AFD6>]/Index[234 36]/Info 233 0 R/Length 106/Prev 161226/Root 235 0 R/Size 270/Type/XRef/W[1 3 1]>>stream This authorization expires on _____, or six (6) (DATE) months from the date of signature, whichever is sooner. Authorization of Minors: If the patient is a minor (under 18 years of age) the authorization must be signed by a parent or legal guardian. Decide on what kind of signature to create. Al hacer clic en el botn Aceptar, acepta el uso de estas tecnologas y el procesamiento de tus datos para estos propsitos. CF 31 (4/15) - CalFresh Supplemental Form For Special Medical Deductions. Here's How, CW 2166 (4/21) - Multilingual Work Really Pays! %PDF-1.7 % :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 However, there iscertain data that a person will not be able to easily lay his hands on for either two reasons: the data is confidential, or that person is not authorized. The DSHS 14-532 authorized representative form shall be used when a client is authorizing an AREP at a time other than at application or eligibility review. APPOINTMENT OF REPRESENTATIVE. The AREP information shall be reviewed at recertification. 2y.-;!KZ ^i"L0- @8(r;q7Ly&Qq4j|9 EMC endstream endobj 230 0 obj <> stream 67 0 obj <> endobj STATEOFCALIFORNIA-HEALTHANDHUMANSERVICESAGENCY CALIFORNIADEPARTMENTOFSOCIALSERVICES. 1034 0 obj <>stream AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION & APPOINTMENT OF REPRESENTATIVE HBEX 403 (07/17) Page 2 Consumer Authorization By my signature, I hereby authorize Covered California, to release the following personal information to the individual or entity identified below: Name of Individual or Entity: Street Address: City and State: Zip Code: endstream endobj 231 0 obj <> stream This is the most common among these four sectors since employers are well-known for sending out an authorization to access their employees employment history, salary, and previous income statements. AD 4324 (2/21) - Adoption Questionnaire I This is a large PDF file. %%EOF This form authorizes the release of medical information to the representative . Student Financial Aid Verification CSF 50 (English and Spanish) Additional Forms. CSF 14: Authorization for Release of Information - Authorized Representative. CF 37 (7/15) - Recertification For CalFresh Benefits. endstream endobj 233 0 obj <> stream Posted on . FDU 113 (7/22) - Civil Rights Annual Training Checklist For CSFP And TEFAP, FS 31 ENG/CH (2/09) - Notice To All Food Stamp Recipients - Important-Please Read - Things You Need To Know, FSP 1 (8/14) - Family Stabilization Program Evaluation Request, FSP 2 (1/21) - Family Stabilization Program Denial Notice, FSP 3 (8/14)Family Stabilization Program Notice of Change in Program Status, GEN 111 (11/20) - Employer Statement Form, GEN 1179 (5/18) - Complaint of Discrimination, GEN 1388 (9/15) - Language Accessibility Services Complaint Form, GEN 1390 (3/17) - Informing Notice - Regarding An Action Taken On Your Case, HCS 100 (11/21) - Application For Home Care Aide Registration or Renewal, IHSS-E 002 (1/17) - In-Home Supportive Services (IHSS) Program Notice To Provider For Discontinuance Of Exemption From Workweek Limitations For Extraordinary Circumstances, IHSS-E 003 (1/17) - In-Home Supportive Services (IHSS) Program Notice To Recipient For Discontinuance Of Exemption From Workweek Limitations For Extraordinary Circumstances, IHSS-E 004 (4/17) - In-Home Supportive Services Program Notice Of Non-Receipt Of Exemption From Workweek Limits Provider Agreement (APD 006), IHSS-E 005 (1/17) - In-Home Supportive Services Program Notice Of Ineligibility To Request Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2) - Provider, IHSS-E 006 (4/17) - In-Home Supportive Services Program Notice To Provider Of Expiration Of Exemption From Workweek Limits, IHSS-E 007 (4/17) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Providers Expiration Of Exemption From Workweek Limits, KG 2 (1/11) - Statement Of Facts Supporting Eligibility For Kinship Guardianship Assistance Payment (Kin-GAP) Program, KG 3 (12/11) - Kin-GAP Mutual Agreement For Nonminor Former Dependents, KG 4 (2/14) - Kinship Guardianship Assistance Payment (Kin-GAP) Program - Nonrecurring Legal Guardianship Expenses Agreement, KG 5 (2/14) - Kinship Guardianship Assistance Payments (Kin-GAP) Program Nonrecurring Legal Guardianship Expenses Form, LIC 00 (8/17) - Conversion to Resource Family: Release of Information, LIC 00A (2/17) - Conversion - Resource Family Application, LIC 01A (8/21) - Resource Family Application, LIC 01C (7/16) - Resource Family Application-Confidential, LIC 03 (8/21) - Resource Family Home Health And Safety Assessment Checklist Document For Agency Use Only, LIC 05A (8/21) - Resource Family Approval Certificate, LIC 12 (8/21) - Resource Family Approval Document Alternative Plan (DAP), LIC 126 (3/21) - Entrance Checklist - Family Child Care Homes, LIC 184B (3/22) - Notification Of Incomplete Application - Family Child Care Home, LIC 184C (3/22) - Notification Of Incomplete Application (NOIA) Child Care Centers -Pre-30-Day NOIA, LIC 184D (3/22) - Notification Of Incomplete Application (NOIA) Child Care Centers - 30-Day NOIA, LIC 184E (3/22) - Notice Of Incomplete Application (NOIA) Changes To Corporate Status, LIC 198 (1/22) - Child Abuse Central Index Check For County Licensed Facilities, LIC 198B (8/21) - Out-Of-State Child Abuse/Neglect Report Request, LIC 200 (2/11) - Application For A Community Care Facility or Residential Care Facility For The Elderly License, LIC 279 (2/09) - Application For A Family Child Care Home License, LIC 279B (1/22) - Current Children In Your Home - Application For A Family Child Care Home License, LIC 281D (1/17) - Application And Supporting Documentation Checklist Foster Family Agency, LIC 281E (1/17) Application And Supporting documentation Checklist Short - Term Residential Therapeutic Program, LIC 300A (01/22) - Removal Confirmation - Exemption Needed, LIC 301E (10/22) - Reference Request - Exemption, LIC 311A (2/22) - Records To Be Maintained At The Facility - Child Care Centers, Infant Centers, School-Age Centers and Child Care Centers For Mildly Ill Children, LIC 421CC (6/22) - Civil Penalty Assessment Child Care, LIC 421D (CC) (8/22) - Civil Penalty Assessment Death/Serious Injury/Physical Abuse (Child Care), LIC 311D (2/22) - Forms/Records To Keep In Your Family Child Care Home, LIC 421A (6/22) - Civil Penalty Assessment (Unlicensed Facility), LIC 508D (8/17) - Out-Of-State Disclosure And Criminal Record Statement, LIC 610A (01/22) - Emergency Disaster Plan For Family Child Care Homes, LIC 610B (6/02) - Emergency Plan For Foster Family Homes, LIC 613A (8/08) - Personal Rights - Child Care Centers, LIC 613B (6/22) - Personal Rights Childrens Residential Facilities, LIC 624B (8/08) - Unusual Incident/Injury Report - Family Child Care Home, LIC 700 (10/19) - Identification And Emergency Information Child Care Centers/Family Child Care Homes, LIC 702 (8/08) - Child's Preadmission Health History - Parent's Report, LIC 995 (9/08) - Child Care Center - Notification Of Parents' Rights, LIC 995A (8/08) - Family Child Care Home - Notification Of Parents' Rights, LIC 995B (8/08) - Family Child Care Home Addendum To Notification Of Parents' Rights (Regarding Removal/Exclusion), LIC 995C (8/08) - Family Child Care Home Addendum To Notification Of Parents' Rights (Regarding Reinstatement), LIC 995E (10/09) - Caregiver Background Check Process, LIC 995F (10/09) - Caregiver Background Check Information, LIC 9058 (3/22) - Applicant/Licensee Rights, LIC 9108 (3/05) - Statement Acknowledging Requirement To Report Suspected Child Abuse, LIC 9148 (9/00) - Earthquake Preparedness Checklist (EPC), LIC 9149 (8/14) - Family Child Care Home Property Owner/Landlord Consent Form, LIC 9150 (8/14) - Parent Notification - Additional Children in Care, LIC 9151 (8/14) - Property Owner/Landlord Notification Family Child Care Home, LIC 9163 (3/21) - Request Live Scan Service - Community Care, LIC 9217 (5/22) - Pre-Licensing Readiness Guide - Family Child Care Home, LIC 9221 (5/22) - Parent Consent For Administration Of Medications And Medication Chart, LIC 9224 (8/08) - Acknowledgement Of Receipt Of Licensing Reports, LIC 9227 (8/20) - Individual Infant Sleeping Plan, M16-120B (6/11) - EBT Dormat Account: Suspend, M16_120C (7/02) - EBT Dormant Account - Reactivate, M16_325B (7/02) - EBT Incomplete Document, M16-325E (8/08) - Direct Deposit Cancellation, M16_505A (7/02) - Designated Alternate Cardholder, M16_505B (7/02) - Designated Alternate Cardholder - Need Additional Fact, M16_505D (7/02) - Designated Cardholder - Deny, M20-003 (7/01) - Duplicate Aid Match, Discontinue, M20-003A (7/01) - Duplicate Aid Match, Deny, M20-353C (6/98) - Fraud, Penalty Applied to AU, M20-353D (6/98) - Fraud, Penalty Applied to AU, M20-353F (6/98) - Fraud, Penalty Stops - Change, M40_105 (11/14) - Failed to Provide SSN When Received or Failure to Cooperate, M40_105A (11/14) - Failed to provide SSN or proof of completed SSN Application, M40_105B (7/98) - Change: Required Documentation Received, Immunization, M40_105C (11/14) - Notice of Action - Immunizations, M40_105D (7/98) - Change: Required Documentation Received, School Attendance, M40-105D1 (1/15) - Notice Of Action - School Attendance, M40_105E (2/15) - Notice of Action - School Attendance, M40_105I (3/00) - Deny: SFIS Requirements, Failure to Cooperate, M40_105J (3/00) - Deny: SFIS Requirements, Refusal to Cooperate, M40-107 (6/11) - Addendum 1 - Child Support Collection For CalWORKs 48-Month Time Limit Exemption, M40-107 (4/21) - Addendum 1 - Child Support Collection For CalWORKs 60-Month Time Limit Exemption, M40-107 (6/11) - Addendum 2 - Child Support Collection For CalWORKs 48-Month Time Limit Exemption, M40-107 (4/21) - Addendum 2 - Child Support Collection For CalWORKs 60-Month Time Limit Exemption, M40_107A (11/02) - Other: CalWORKs 60-Month Time Limit, Time on Aid (no previous NOA issued), M40-107A (4/21) - Time On Aid (no previous NOa issued), Other, M40_107B (6/11) - Time on Aid at Redetermination, M40-107B (4/21) - Time On Aid at Redetermination, M40-107C (6/11) - Time On Aid Between 42th and 46th, M40-107C1 (9/20) - Time on Aid Between 54th and 57th Month - Use Starting May 1, 2022, M40-107D (6/12) - Time On Aid To Former CalWORKs Recipients, M40-107D (4/21) - Time On Aid To Former CalWORKs Recipients, M40_107F (6/11) - Extended Beyond 48 Months Of Aid, M40-107F (4/21) - Extended Beyond 60 Months of Aid, M40-107F1 (4/21) - Extender Met After 60th Month, M40_107F1 (6/11) - Extender Met After 48th Month, M40_107G (11/02) - Discontinue: CalWORKs 60-Month Time Limit, 60th month on Aid, M40-107G (4/21) - 60th Month On Aid, Discontinue, M40_107H (11/02) - Change: CalWORKs 60-Month Time Limit, 60th month on Aid MFG child only, M40-107I (7/22) - 60th Month On Aid, No eligible child, Discontinue, M40_107J (11/02) - Partial Approval: CalWORKs 60-Month Time Limit, Time-Out Adult, M40-107J (4/21) - Timed-Out Adult, Partial Approval, M40_107J1 (6/11) - Approval after 48 Months On Aid, M40-107J1 (4/21) - Approval After60 Months on Aid, M40_107K (6/11) - Increase Grant due to TOA Adjustment, M40-107K (4/21) - Increase Grant due to TOA Adjustment, M40_118A (8/96) - Application Processing Deny, M40-125B SAR (4/16) - Restore After a SAR7 Discontinuance, M40-125C SAR (4/16) - Incomplete Semi-Annual Report (SAR7) Denial of Restoration, M40 129B (11/09) - Full Payment - Approve, M40-129B1 (12/90) - Approval after Immediate Need Payment, Approve, M40-129D1 (11/14) - Procedural Requirements, Deny, M40-129D2 (12/90) - Procedural Requirements, Deny, M40-129D3 (12/90) - Procedural Requirements, Deny, M40-129D4 (9/00) - Procedural Requirements, Deny, M40_129D5 (11/14) - Failed to Provide Proof of SSN Application, Deny, M40-171A (11/14) - Failure to Cooperate, Deny, M40-171B (5/91) - Refusal to Cooperate, Deny, M40_171C (6/98) - Approve: Application Processing, Basic Approval, M40_171M (7/87) - Denial: Application Processing, Not a California Resident, M40 181 (9/13) - SAWS 2 Redetermination Of Eligibility, M40-181A (11/14) - SAWS 2 Redetermination/Other Essential Information, M40_181E (11/14) - SAWS 2 PLUS Redetermination Immunizations/School Attendance, Change, M40 181C SAR (9/13) - Notice Of Action - Balderas Reminder Notice, M40-181F (7/22) - No Change at Redetermination, M40-195A (8/22)- ICTNotice Of Transfer, Sending, M40-195B (8/22) - ICT Notice Of Transfer, Receiving, M41_401A (12/86) - Denial: Deprivation, No Deprivation, M41_440F (6/98) - DENY: Deprivation, CalWORKs-U, 100 Hours Work Rule, M41_450A (1/98) - Deprivation: Uniformed services - Deny, M42_101B (11/14) - Age and School Requirements, M42-101C (11/14) - Age and School Requirements, Discontinue, M42 207A (10/15) - Over Property Limit, Deny, M42_221K (4/99) - Suspend: Property, Transfer w/out Fair Consideration, M42_221L (4/00) - Suspend: Income, Transfer w/out Fair Consideration, M42-431A4 (11/14) - No Eligible Noncitizen Status/Proof of Eligible Noncitizen Status, Discontinue, M42-769A (11/14) - Apply $100 Cal-Learn Penalty, M43_119E (1/98) - Sponsored Non-Citizen: Some needs Met - Change, M43_119G (11/14) - Missing SAR 72, Change, M43-119H (11/14) - Missing SAR 72, Discontinue, M43_119I (7/98) - Change: Sponsored Alien, Deemed & Family Property, M43_119J (7/98) - Change: Sponsored Alien, Deemed Property, M43_119K (7/98) - DENY: Sponsored Alien, Deemed Property & Family Property, M43_119L (7/98) - DENY: Sponsored Alien, Deemed Property, M43_119M (1/98) - Sponsored non-Citizen: Deemed Income-Change, M44_113A (6/98) - Change: Income, Change in Income, M44_113G1 (6/98) - Change: Income, Change in Income, M44_133D (6/98) - Change: Income, Change in Income, M44_133Q (6/98) - Change: Income, Change in Income, M44_133S (10/02) - Minor Parent Financial Eligibility (Change), M44-133T (9/20) - Minor Parent, Financial Eligibility, Partial Approval, M44_133V (10/02) - Minor Parent Financial Eligibility (Suspend), M44-207I SAR (4/16) - Financial Eligibility, M44_207J (6/98) - DENY: Income, Financial Eligibility Test, M44_207L (6/98) - SUSPEND: Income, Financial Eligibility Test, M44-207K (5/20) Financial Eligibility, Discontinue, M44-207K1 (5/20) - Minor Parent, Financial Eligibility, M44-207M (8/20) - Financial Eligibility, Deny, M44-211B (10/21) - Expanded Temporary HA For Applicants Fleeing DV, Approve, M44-211D (10/21) - Temporary Shelter And/Or Permanent Housing, M44_211L (7/01) - Change: Special Needs - Pregnancy, M44-211N (9/21) - No Longer Pregnant, Change, M44_305 (9/97) - Minor Parent Change of Payee, M44_307A (11/15) - Voucher/Vendor Payment, Other, M44-315A (5/20) - $10 Minimum Payment, Change, M44-315A (8/21) - $10 Minimum Payment, Change, M44_315B (9/98) - CHANGE: Aid Payment Levels, ICT between Reg-2, M44 315C (4/09) - Notice of Action - Four Percent Grant Reduction, M44 316 (8/04) - No Change/Mid Quarter Reporting, M44 316 SAR (9/13) - No Change/Mid-Period Reporting, M44 316A (9/13) - Notice Of Action - Not Yet Changed, M44 316B (9/13) - Notice Of Action - Change In Income Over IRT, M44-316C (8/22) - Notice Of Action - No Change/Mid-Period Report Of Property, M44 316C SAR (10/17) - No Change/Mid-Period Report of Property, M44 316D SAR (9/13) - Notice Of Action - Change In Income, M44-316E (10/16) - Mid-Period Change Due To The Death Of A Child, M44_340 (4/00) - Approval: Underpayments, Underpayment Adjustment, M44 340C (8/12) - Underpayment Adjustment, M44_350A (11/11) - Overpayment Adjustment, M44_350E (11/11) - Excess Property Overpayment Adjustment (W/O Good Faith), M44_350F (11/11) - Excess Property Overpayment Adjustment (W/O Good Faith), M44_350G (11/11) - Excess Property O/P Adjustment (with Good Faith), M44_350H (11/11) - Excess Property Overpayment Adjustment (With Good Faith), M44-350I SAR (9/13) - Notice Of Overpayment, M44-350J (3/12) - Overpayment To Be Stopped Effective February 1, 2012, M44-350K (11/21) -EBT Replacement Denial, M44_352A (11/11) - Notice of O/P and Demand, M44-352H (11/11) - Overpayment Adjustment, M44 352H SAR (9/13) - Notice Of Action Overpayment Adjustment, M44_401A (6/98) - Approve: Hardship Supplement RISP - MFG, M44_401B (6/98) - Deny: Hardship Supplement RISP - MFG, M81_215A (6/98) - DENY: Aid Payments, Diversion payment provided, M81_215B (6/98) - DENY: Aid Payments, Diversion services provided, M81_215D (6/98) - Change: Aid Payments, Diversion Repayment Stops, M82-506 (6/98) - Change: Assignment of Support Rights, Failure to Cooperate, M82-506A (6/98) - Partial Approval: Assignment of Support Rights, Failure to Cooperate, M82-510 (6/02) - Failure to Cooperate, Change, M82-510A (6/98) - Change: Support Process/Assignment, Cooperate, M82-812 (4/04) - Family Reunification/Zero Grant, M82-820A (9/21) - No Eligible Person, Deny, M82-832A (2/99) - Change: Aid Payments, Fleeing Felons, M82-832B (2/99) - Partial Approval: Application Processing, Fleeing Felons, M82-832E (4/15) - Eligible Person Leaving AU, Change, M82-832F (4/15) - Eligible Person Leaving AU, Discontinue, M82-832G (6/18) - Eligible/Mandatory/Optional Person Leaving AU, M82-832H (10/20) - Child Does Not Meet Requirements (SB 380), M82-836A (8/91) - Denial: Au Composition, Unborn not Eligible for Aid, M89-130 (1/02) - Restricted Account, Discontinue, M89_201 (11/96) - Minor Parent exemption: Deny, MT42_101.2D (11/04) - Fry vs Saenz Lawsuit Age Requirement - Change, MT42_101.2E (11/04) - Fry vs Saenz Lawsuit Age Requirement - Discontinue. this year i really want to answer, speedway credit card charge, sally rand collection antique archaeology,

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