PDF Authorized Representative/ HIPAA Form - BenefitHelp Solutions csf 14 authorization for release of information authorized representative. Here's How, CW 2166 (11/21) - Multilingual Work Really Pays! The patient or legally authorized representative must sign and date the form. The following formsneed tobecompletedduringforthe GA applicationprocess. 1034 0 obj <>stream Follow this simple instruction to edit California calfresh authorization online in PDF format online for free: . This form authorizes the release of medical information to the representative . Q(*HetMS< U~8 x,O Health Insurance Premium Program (HIPP) Application. On-line Forms and Publications A - D - California Department of Social EMC 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. CSF 14: Authorization for Release of Information - Authorized Representative. I appoint this individual _____ / _____ Name of individual Name of organization . "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 There are three variants; a typed, drawn or uploaded signature. EMC [7 U.S.C. MCED Forms Spanish - California Don't addthe new AREP untilwe receive: a signed Eligibility Review form with completed AREP section. 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. 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 230 0 obj <> stream NOTE: Some links on this page are documents in Adobe . Medical and healthcare agencies. Title 22 of the . endstream endobj 231 0 obj <> stream Medi-Cal Forms - California 269 0 obj <>stream PDF 14-532 Authorized Representative - Washington SECTION I. 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. 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. M. C 382 (6/18) Use this form to appoint an individual or organization as your Medi-Cal authorized representative. PDF GOVERNMENT OF THE DISTRICT OF COLUMBIA - Washington, D.C. 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. 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.

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