How to identify and code an AREP in our automated systems. 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. Generally, only a patient may authorize release of his/her medical information. The Authorizing Individual. [7 U.S.C. xc``a``b```a@@1CD'{> %k( %%EOF CalFresh Application CF 285 (English) Dual Application SAWS2Plus . 269 0 obj <>stream Application Forms - Alameda County Social Services Here's How, CW 2166 (4/21) - Multilingual Work Really Pays! endstream endobj 890 0 obj <>/Subtype/Form/Type/XObject>> stream APPOINTMENT OF REPRESENTATIVE. PDF Consent - Washington 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. endstream endobj startxref We help individuals, families, and communities access services and public benefits that make a difference in their lives. Completing the DSHS 14-532 AREP form isn't required if the clientis confirming or making changes to their current AREP. 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. @ PAA $|TAPAA $|TAPAA $|Tadm:=gUEIb> @8&|A849YiG, l 6w '7 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. %=coF5H_}{AWwEPY]1BE8=mF~tU3PI3=^mdHCgIsME>5s4Y|hhBo(cHivU.-KGr0h_i9R .r>&S6h. PDF 14-532 Authorized Representative - Washington 102 0 obj <>stream PDF AUTHORIZED REPRESENTATIVE - California Department of Social Services Authorization to release information to re: Fill out & sign online | DocHub 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 You do not need to print these forms as they will be mailed to you after you submit your initial application form. Tips for Using Adobe PDF Files. 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 895 0 obj <>/Subtype/Form/Type/XObject>> stream Clients must complete a DSHS 14-532 AREP form when designating a new AREP. endstream endobj 888 0 obj <> endobj 889 0 obj <>/Subtype/Form/Type/XObject>> stream Make sure it's consistent with what the client indicated on the review form. TO BE COMPLETED BY APPLICANT / BENEFICIARY . Hln0z;PJkK"D6~9)a'Gf4OcH|.jDry6vn[U)}SpwS[ la persona asignada para el proceso de legalizacin en los distintos Ministerios, Cmaras, Consulados y Organismo Oficiales que requiera, con ms de 20 aos de experiencia Contamos tambin con traductores Jurados reconocidos por el Ministerio de Asuntos Exteriores, 2022 Apostilladodelahaya.comTodos los derechos reservados, 2022 Apostilladodelahaya.com Todos los derechos reservados. 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. CF 32 (6/13) - CalFresh Request For Contact. Review these documents as they have important information regarding your application. lx}I=u1\=VrN!F\UlRpDRhO|#s9c^l~3e;12qCqB*.3P-J=*S=+OeD^_ ,rZ Authorized Representative - Food, Cash and Medical Benefit Issuances EMC N')].uJr The Public Disclosure Unit is responsible for approving or denying requests for disclosure of confidential information. H\n@E,Sec%Ri:`!aw`WYtmM&O.LfeCgizJ>VCw)}{2u7a^~|nfm.Lf3x|_1}cT}jy0V!de1UB|gr~fT"`mX p@ % (jP Dental, Request for Access to Protected Health Information. See the Authorized Representative Payee Chart. Or, you may also limit duties. Your authorized representative may act for you on all duties related to your Medi-Cal eligibility and enrollment. FCCH - Pre-Orientation Registration Information: Wait! %%EOF fSZHti>DB6O,? Nuestro personal est altamente cualificado. its regulations and Quieres probar una bsqueda? 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. endstream endobj startxref H|n@,SEKlp5i"o93vtEew~iyL7{l4MW_jpymf_y>qli|?O]0w2GlH6tyW?wKYX~bcdo9gL[^KQ (m6 K%%@IX apes chapter 4 quizlet multiple choice. 2. xcbd```b``V}`r5dXWd +D2)H "0012d[20j?cS&.@~{ h! endstream endobj 141 0 obj <. Tn+P6z! ^.K(uA_D6}\9P(|$I'1'O+bJ+RWL^3UT`>S)mbb6JF)P 16x;ltAx}0 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. endstream endobj 230 0 obj <> stream Chinese A-M - California Department of Social Services hb```"oV)af`0p &I0nafX4AD?P`YJD!NMV$2F3{i1 032p040060`}Pht@/ABo].T.`FY?R~04\.zd'&?Jl| @ H/M An AREP can receive letters, including the income computation sheet, renewal forms, and ProviderOne services cards if the client has authorized the sharing of such correspondence. A Financial Authorization Form is also used by business men in allowing their trusted representatives to transact an amount on their behalf. An AREP may receive letters/notices/forms/warrants/EFT/ProviderOne service cards or they may have permission to only discuss the case and not receive any written correspondence. f8EN*ZY\?PQH~>}vfy*2`V6]k=_Oh5p|0 t6?2fS.\v4 `c9-rf;(T3:5I_d81Xuowf'dzG6_`EpC#b@FC>@M\4f+xTK9s/)-xL);P H^t-$?Lo)17?R|osx?t81x{e4RlP])[Y>. hbbd``b`f@@2{ Loma`%3_ab`W, 6\G Cal Fresh Forms + Resources San Diego Hunger Coalition 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. %PDF-1.7 % endstream endobj 900 0 obj <> stream AMedical Authorization Formmay be completed by the administering physician to acquire the medical records of his patient. MCED Forms Spanish - California 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. csf 14 authorization for release of information authorized representative illinois obituaries 2020 . Box 12941, Oakland, CA 94604. Notice to Terminating Employees. Printable Forms. When to require the DSHS 14-012(x) consent form. 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. csf 14 authorization for release of information authorized representative. 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. When to require the DSHS 14-012 (x) consent form. For information regarding AREP for Long-Term Care cases see: Long-Term Care AREP or WAC -Long-Term Care for Families and Children. CF 29D (2/14) - CalFresh Recertification On-Demand Appointment Letter. CHECK ONE Patient Parent Domestic Authorized Representatives for hearing purposes pursuant to . 9A~c+e!0Ow ;3`yKn:nSL5)@~rMBEr~u8pAYh="4e3&X\6H(Tzzop|kUM.Mwcfe FKJj6 B^v 886 0 obj <> endobj 936 0 obj <>/Filter/FlateDecode/ID[(\326\207Z2N\272\261I\266\305#\003b\307\005+) (\306o\226_\362i\tK\273\200\262\254> stream The table lists the various MA forms and envelopes available to providers. Name . they receive. 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 The following forms need to becompleted duringfortheCalFreshapplication and renewal processes. H\Mj0>37"),CFq}0 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. The REP Type code on the AREP screen determines what forms, letters, etc. 0 EMC hXmo6+aD"@/@-}p-nQ[qduyG1xa_Q"F)|+Nxb4Fl,S`# Cal program to send the CSF 14 to applicants/beneficiaries to appoint a Medi-Cal AR? The records of a students grades and transcript from the previous university will be disclosed with the aid of a Transcript Release Authorization Form. 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 Authorized Representative Name: Authorized Representative Address: Authorized Representative Telephone Number: I authorize the above designated individual to act as my representative for the purposes checked below. endstream endobj 68 0 obj <>>>/Filter/Standard/Length 128/O(! Third Party Liability Notification. csf 14 authorization for release of information authorized representative. AREPs are not automatically eligible to be an EBT Alternate Card Holder for Basic Food or cash benefits. csf 14 authorization for release of information authorized representative. information without appointing an AR using a written authorization, such as a "Release of Information" form, or a telephonic authorization. PDF HBEX403 Authorization to Release PII and Appointment of Representative HIPAA restrictions prevent us from discussing the client's individual health information with an AREP unless a current signed DSHS 14-012(x) consent form is in the record. HPN07UI DJd(T$0tssdq,N{;Z5uczrhF: mH^_ -1j$#w+:gnUs?7]C-=HT;.h`_bX{,UF$@rI4Pl^G(b$a?&?/V,] 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 / /Tx BMC The client can identify an AREP on the application, eligibility review form, or DSHS 14-532 authorized representative form. csf 14 authorization for release of information authorized representative. These forms are in Adobe PDF format and you must have a copy of Adobe Acrobat Reader installed on your system to view them. EBT 2259: Report of Electronic Theft of Benefits. AUTHORIZED REPRESENTATIVE,20. When the information is needed from DSHS to administer a DSHS program and get needed services to a client (example; verification for a child care provider; however, only share information that would be necessary for the provider to provide child care). endstream endobj 224 0 obj <> endobj 225 0 obj <>/DA(/Helv 0 Tf 0 g)/F 4/FT/Sig/MK<<>>/Rect[69.0621 355.183 467.077 371.112]/StructParent 7/Subtype/Widget/T(Applicant/Beneficiary's signature)/TU(Please enter the Applicant/Beneficiary's signature)/Type/Annot>> endobj 226 0 obj <>/DA(/Helv 0 Tf 0 g)/F 4/FT/Sig/MK<<>>/Rect[66.8903 104.562 267.71 120.056]/StructParent 10/Subtype/Widget/T(Authorized representative's signature)/TU(Enter the Authorized representative's signature)/Type/Annot>> endobj 227 0 obj <>/Subtype/Form/Type/XObject>> stream For more information see Confidentiality and Public Disclosure. 63-57 CalFresh Application Cover Sheet (multi-language), CW 2223 Demographic QuestionnaireChinese, Spanish, 50-110 Voter Preference FormCambodian, Chinese, Farsi, Spanish, Tagalog,Vietnamese. 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. 1034 0 obj <>stream This includes banks and other agencies who deal with depositing and withdrawing money. Quality Assurance Fee Program. Gathering information is vital for every type of transaction in any organization. The AREP information shall be reviewed at recertification. EMC Notable exceptions to the rule are as follows: a. FREE 15+ Sample Release Authorization Forms in PDF | MS Word | Excel Case number (optional) Date . Choose My Signature. % DSBlank Log on to your account or contact your county office to update your information. Educational Institutions. hbbd``b`Z$@ u@-Dd ^ P*H#_ N + 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. Form . AD 4320 (6/22) - Adoption Assistance Program (AAP) Agreement . A general authorization for the release of medical or other information is NOT sufficient for this purpose. %PDF-1.6 % H\Pj0+t=,G([ Esta web utiliza cookies propias y de terceros para su correcto funcionamiento y para fines analticos. Photocopies of this authorization shall be considered as valid as an original. p()md). EMC Medical and healthcare agencies. When to require the DSHS 17-063 authorization form or HCA 80-020 authorization for the release of information form. This authorization expires on _____, or six (6) (DATE) months from the date of signature, whichever is sooner. Medi-Cal Eligibility Divisi on forms are listed below, alphabetically, by form number and has been translated into Spanish. 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). endstream endobj 899 0 obj <> stream Student Financial Aid Verification CSF 50 (English and Spanish) Additional Forms. /Tx BMC nQt}MA0alSx k&^>0|>_',G! PDF Design Document - CalSAWS Decide on what kind of signature to create. endstream endobj 896 0 obj <>/Subtype/Form/Type/XObject>> stream Posted on . I understand that if I do not check any of the boxes below, my authorized representative will be authorized to perform all of the . 200 0 obj <>stream endstream endobj 897 0 obj <> stream Pn?%9:t 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 0 Recertification CF37 . 2y.-;!KZ ^i"L0- @8(r;q7Ly&Qq4j|9 0,00 . Medi-Cal MC 382: Appointment of Authorized Representative Cambodian, Chinese , Farsi, Spanish, Tagalog, Vietnamese MC 383: Authorized Representative Standard Agreement for Organizations. The Information to be Released. 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. AREP designation isn't valid after the certification period. 6m5q'b` HX$a c @55| /MS9 Form processing may be delayed if fields with an asterisk are not filled out. The following forms need to becompleted duringfortheMedi-Calapplicationprocess. HTP=o ',V58)RC!C}MH g?=FoaF3i uP`{zT8u8@JsaSu+n7"k03h-.+AA5t2/+Rz3>&3n'!0N-@0 NiA@}n9r?%#  Document extensions or changes to the designated AREP in ACES. N')].uJr See AREP definition above. 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: June 29, 2022; creative careers quiz; %PDF-1.7 % HyTSwoc [5laQIBHADED2mtFOE.c}088GNg9w '0 Jb SIGNATURE . 14-532 Authorized Representative Author: Brombacher, Millie A. An AREP assists the client with the application, recertification, and general eligibility processes.