csf 14 authorization for release of information authorized representative

SECTION I. AREP designation isn't valid after the certification period. Box 12941, Oakland, CA 94604. Parece que no se ha encontrado nada en esta ubicacin. El asesor que se le asignar tendr una comunicacin directa desde el principio hasta el final de su gestin y entrega. 0. Authorized Representative/ HIPAA Form PLEASE PRINT CLEARLY * This information is mandatory. Authorized Representative/Protective Payee, Authorized Representative - Food, Cash and Medical Benefit Issuances, Washington State Department of Social and Health Services, Aging and Long-Term Support Administration (ALTSA), Developmental Disabilities Administration (DDA), Facilities, Finance and Analytics Administration (FFA), Payees on Benefit Issuances - Authorized Representatives, ABD Clients Residing in Eastern or Western State Hospital, Administrative Disqualification Hearings for Food Assistance, Administrative Hearing Coordinator's Role, Pre-Hearing Conference With An Administrative Law Judge, Pre-Hearing Meeting With the DSHS Representative, Special Procedures on Non-Grant Medical Assistance and Health Care Authority hearings, Information Needed to Determine Eligibility, Authorized Representative - Food Assistance, Automated Client Eligibility System (ACES), Basic Food Employment and Training (BFET) Program, BFET - Reimbursement of Participant Expenses, Basic Food Work Requirements - Work Registration, ABAWDs- Able-Bodied Adults Without Dependents, Basic Food Work Requirements - Good Cause, Basic Food Work Requirements - Disqualification, Basic Food Work Requirements - Unsuitable Employment and Quitting a Job, Cash and Medical Assistance Overpayment Descriptions, Recovery Through Mandatory Grant Reductions, Repayments for Overpayments Prior to April 3, 1982, Loss, Theft, Destruction or Non-Receipt of a Warrant to Clients or Vendors, Chemical Dependency Treatment via ALTSA and Food Assistance, Citizenship and Alien Status Requirements for all Programs, Citizenship and Alien Status - Work Quarters, Citizenship and Alien Status Requirements Specific to Program, Citizenship and Alien Status - For Food Benefits, Citizenship and Alien Status - For Temporary Assistance for Needy Families (TANF), Citizenship and Alien Status for State Cash Programs, Public Benefit Eligibility for Survivors of Certain Crimes, Citizenship and Identity Documents for Medicaid, Citizenship and Alien Status - Statement of Hmong/Highland Lao Tribal Membership, Confidentiality - Address Confidentiality Program (ACP) for Domestic Violence Victims, Consolidated Emergency Assistance Program (CEAP), Eligibility Review Requirements for Cash, Food and Medical Programs, Eligibility Reviews/Recertifications - Requirements for Food and Cash Programs, Consolidated Emergency Assistance Program - CEAP, Disaster Supplemental Nutrition Assistance Program (D-SNAP), Emergency Assistance Programs - Additional Requirements for Emergent Needs (AREN), Equal Access (Necessary Supplemental Accommodations), Food Assistance - Supplemental Nutrition Assistance Program (SNAP), Food Assistance Program (FAP) for Legal Immigrants, Food Distribution Program on Indian Reservations, Foster Care/Relative Placement/Adoption Support/Juvenile Rehabilitation/Unaccompanied Minor Program, Health Care Authority - Apple Health (Medicaid) Manual, Healthcare for Workers with Disabilities - HWD, Indian Agencies Serving Tribes With a Near-Reservation Designation, Effect of the Puyallup Settlement on Your Eligibility for Public Assistance, Income - Indian Agencies Serving Tribes Without a Near-Reservation Designation, Income - Effect of Income and Deductions on Eligibility and Benefit Level, Lottery or Gambling Disqualification for Basic Food, Lump Sum Cash Assistance and TANF/SFA-Related Medical Assistance, Payees on Benefit Issuances - Protective Payees, Pregnancy and Cash Assistance Eligibility, Food Assistance Program for Legal Immigrants (FAP), Housing and Essential Needs (HEN) Referral, Refugee - Immigration Status Requirements, Refugee - Employment and Training Services, Refugee Resettlement Agencies in Washington, How Vehicles Count Toward the Resource Limit for Cash and Food, Supplemental Security Income and State Supplemental Payment, Transfer of Property for Cash and Basic Food, Authorized Representative - Food Assistance, Automated Client Eligibility System (ACES) , Office of Refugee and Immigrant Assistance, When release is required by law (commonly by court order or subpoena); or. Completing the DSHS 14-532 AREP form isn't required if the clientis confirming or making changes to their current AREP. 6m5q'b` HX$a c @55| /MS9 N')].uJr endstream endobj 893 0 obj <>/Subtype/Form/Type/XObject>> stream csf 14 authorization for release of information authorized representative. 2y.-;!KZ ^i"L0- @8(r;q7Ly&Qq4j|9 SAWS 2 Plus:Application forCalFresh, Cash Aid, and/or Medi-CalCambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, Other languages, CF 285: Application for CalFresh BenefitsCambodian, Chinese,Farsi,Spanish,Tagalog, Vietnamese, Other languages, CF 37: Recertificationfor CalFresh BenefitsCambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, Other languages, CCFRM604: State of California Health Insurance ApplicationCambodian,Chinese, Farsi, Spanish,Tagalog,Vietnamese, Other languages, 90-16:Application for General Assistance, SOC 814:Statement of Facts Cash Assistance Program for Immigrants (CAPI)Chinese, Spanish, Other languages, 90-152:GA Accomodation RequestSpanish,Cambodian,Chinese,Farsi,Vietnamese, SAR 7:Eligibility Status ReportCambodian, Chinese, Farsi, Spanish,Tagalog,Vietnamese,Other languages, SAR 3: Mid-Period Status Report For Cash Aid and CalFreshCambodian, Chinese,Farsi, Spanish,Tagalog,Vietnamese,Other languages, CalWORKs, CalFresh, Refugee Cash Assistance, and General AssistanceCSF 14: Authorization for Release of Information - Authorized Representative, Medi-CalMC 382: Appointment of Authorized RepresentativeCambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, MC 383: Authorized Representative Standard Agreement for Organizations, CAPIC-776:CAPI Authorized Representative Form. %PDF-1.7 % AD 4324 (2/21) - Adoption Questionnaire I This is a large PDF file. H\0 endstream endobj 895 0 obj <>/Subtype/Form/Type/XObject>> stream 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 Notice to Terminating Employees. _gL7YG{b>v#F>//C1n taqOY__5UUeKZ\Uq2~?&Ymn J?4y/*Eue!~VUYTqZy?6u=gD Nx>mp ((J,8p Fh 2y.-;!KZ ^i"L0- @8(r;q7Ly&Qq4j|9 "J@B+$)5@h(-4:H.HHr=0ZP2,Ea qt)4/F.z When to require the DSHS 14-012(x) consent form. 234 0 obj <> endobj /%9TB!:(zQRN Form . A(pQ!R(PRBEe8R$d,J8JNM6-q 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. 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. xc``a``b```a@@1CD'{> %k( Gathering information is vital for every type of transaction in any organization. H\Mj0>37"),CFq}0 Make sure it's consistent with what the client indicated on the review form. Al hacer clic en el botn Aceptar, acepta el uso de estas tecnologas y el procesamiento de tus datos para estos propsitos. Pn?%9:t Choose My Signature. 2020 (e) (7); 7 C.F.R. @ PAA $|TAPAA $|TAPAA $|Tadm:=gUEIb> @8&|A849YiG, l 6w '7 The client can identify an AREP on the application, eligibility review form, or DSHS 14-532 authorized representative form. 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- Medi-Cal Eligibility Divisi on forms are listed below, alphabetically, by form number and has been translated into Spanish. %PDF-1.6 % The REP Type code on the AREP screen determines what forms, letters, etc. hbbd``b`f@@2{ endstream endobj 228 0 obj <> stream Quality Assurance Fee Program. 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 Record the representative's name and address on the AREP screen in ACES. I understand that I may receive a copy of this authorization. We help individuals, families, and communities access services and public benefits that make a difference in their lives. See the Authorized Representative Payee Chart. 63-57 CalFresh Application Cover Sheet (multi-language), CW 2223 Demographic QuestionnaireChinese, Spanish, 50-110 Voter Preference FormCambodian, Chinese, Farsi, Spanish, Tagalog,Vietnamese. EMC A: . Loma`%3_ab`W, 6\G 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 /Tx BMC 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: SSP 14 Authorization for Reimbursement of Interim AssistanceChinese, Spanish, 90-117 County of Alameda Lien FormSpanish, CW 2223 Demographic QuestionnaireChinese, Spanish, 50-123 EBT Card and PIN Responsibility Statement, 90-88 General Assistance Program - Health QuestionnaireSpanish, 90-151 Informed Consent for Health QuestionnaireChinese,Spanish, 90-251 CalFresh Employment & Training Program Option to Participate, 90-54 Important Notice to GA Applicants, SAR 7 SAR 7 Eligibility Status ReportCambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, PUB 13 Your Rights Under California Public Benefits Programs - For People ApplyingForOrReceiving Public AidInCaliforniaCambodian, Chinese, Farsi, Spanish, Tagalog, Vietnamese, YAE General Information Notice for the Young Adult Expansion Cambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, OAE General Information Notice for theOlderAdult Expansion Cambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, Alameda County Social Services Agency Home, CalWORKs Initial Application and Redetermination forms, CalFresh Initial Application and Renewal forms, General Assistance (GA) Initial Application and Renewal Application forms, Cash Assistance Program for Immigrants (CAPI) Initial Application forms. Name . Clients must complete a DSHS 14-532 AREP form when designating a new AREP. hb```52@(1{yPdVDHl] O_ $8:)HX 2~F^HHi,l,,&@Spo//;Q#!k84#inpu w S*} # 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. Medical and healthcare agencies. /Tx BMC Delete coded AREP information if you can'tconfirm with the client that it's still valid. 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. Notable exceptions to the rule are as follows: a. endstream endobj 890 0 obj <>/Subtype/Form/Type/XObject>> stream An AREP may receive letters/notices/forms/warrants/EFT/ProviderOne service cards or they may have permission to only discuss the case and not receive any written correspondence. 67 0 obj <> endobj /Tx BMC 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. endstream endobj 897 0 obj <> stream %PDF-1.6 % Printable blank application forms for all our services. June 29, 2022; creative careers quiz; The records of a students grades and transcript from the previous university will be disclosed with the aid of a Transcript Release Authorization Form. The authorized representative can do . EMC 14-532 Authorized Representative Author: Brombacher, Millie A. CF 215 (9/14) - CalFresh Notification Of Inter-County Transfer. endstream endobj 68 0 obj <>>>/Filter/Standard/Length 128/O(! nQt}MA0alSx k&^>0|>_',G! CAPI C-776: CAPI Authorized Representative Form 0 endstream endobj 899 0 obj <> stream endstream endobj startxref 273.2 (n) (1); MPP 63-402.61; ACL 19-55 .] nQt}MA0alSx k&^>0|>_',G! Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. wG xR^[ochg`>b$*~ :Eb~,m,-,Y*6X[F=3Y~d tizf6~`{v.Ng#{}}jc1X6fm;'_9 r:8q:O:8uJqnv=MmR 4 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 / 102 0 obj <>stream Tips for Using Adobe PDF Files. I understand that if I do not check any of the boxes below, my authorized representative will be authorized to perform all of the . Problems with downloading forms? When it's permissible to share information without consent. \(DSHS ASD\) Subject: 14-532 Authorized Representative Keywords: DSHS 14-532 Authorized Representative Created Date: 6/21/2019 10:08:24 AM 961 0 obj <> endobj endstream endobj 892 0 obj <>/Subtype/Form/Type/XObject>> stream %%EOF 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.
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