See the Authorized Representative Payee Chart. endstream endobj 890 0 obj <>/Subtype/Form/Type/XObject>> stream When it's permissible to share information without consent. csf 14 authorization for release of information authorized representative. APPOINTMENT OF REPRESENTATIVE. PDF Appointment of Representative - California 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). HPN07UI DJd(T$0tssdq,N{;Z5uczrhF: mH^_ -1j$#w+:gnUs?7]C-=HT;.h`_bX{,UF$@rI4Pl^G(b$a?&?/V,] PDF 14-532 Authorized Representative - Washington AUTHORIZED REPRESENTATIVE,20. V)gB0iW8#8w8_QQj@&A)/g>'K t;\ $FZUn(4T%)0C&Zi8bxEB;PAom?W= Al hacer clic en el botn Aceptar, acepta el uso de estas tecnologas y el procesamiento de tus datos para estos propsitos. {=:^zu*EQ `mm:HZ2B dIB,bV@@iE @}r:H:2utsb"tt#SIw$ 'Gb'!1.!H]`-T /Tx BMC These forms are in Adobe PDF format and you must have a copy of Adobe Acrobat Reader installed on your system to view them. endstream endobj 231 0 obj <> stream 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. xcbd```b```r5&H2&[k`XW Yq,DH D hbbd```b``"VH2H&c&d,i &YH%91 DH2.g&"+&{*.a`$:F@ PP endstream endobj 230 0 obj <> stream wG xR^[ochg`>b$*~ :Eb~,m,-,Y*6X[F=3Y~d tizf6~`{v.Ng#{}}jc1X6fm;'_9 r:8q:O:8uJqnv=MmR 4 You may cancel or change this appointment at %%EOF hb```"oV)af`0p &I0nafX4AD?P`YJD!NMV$2F3{i1 032p040060`}Pht@/ABo].T.`FY?R~04\.zd'&?Jl| @ H/M 140 0 obj <> endobj 269 0 obj <>stream 9L $? U FCCH - Pre-Orientation Registration Information: Wait! Bs!}\H_`./0Bs! 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. $uH-tH(CjGolH#6J0m0.&X}0Ls cWo { Case number (optional) Date . SSP 14 Authorization for Reimbursement of Interim AssistanceChinese, Spanish, 90-117 County of Alameda Lien FormSpanish, CW 2223 Demographic QuestionnaireChinese, Spanish, 50-123 EBT Card and PIN Responsibility Statement, 90-88 General Assistance Program - Health QuestionnaireSpanish, 90-151 Informed Consent for Health QuestionnaireChinese,Spanish, 90-251 CalFresh Employment & Training Program Option to Participate, 90-54 Important Notice to GA Applicants, SAR 7 SAR 7 Eligibility Status ReportCambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, PUB 13 Your Rights Under California Public Benefits Programs - For People ApplyingForOrReceiving Public AidInCaliforniaCambodian, Chinese, Farsi, Spanish, Tagalog, Vietnamese, YAE General Information Notice for the Young Adult Expansion Cambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, OAE General Information Notice for theOlderAdult Expansion Cambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, Alameda County Social Services Agency Home, CalWORKs Initial Application and Redetermination forms, CalFresh Initial Application and Renewal forms, General Assistance (GA) Initial Application and Renewal Application forms, Cash Assistance Program for Immigrants (CAPI) Initial Application forms. H\Pj0+t=,G([ Student Financial Aid Verification CSF 50 (English and Spanish) Additional Forms. CF 32 (6/13) - CalFresh Request For Contact. endstream endobj 229 0 obj <> stream A relative of the patient may also use an authorization form under this category especially of the patient is a minor and requires a guardian ad he stays in the medical clinic. Medical professionals, financing agents, employers, and even faculty members need to submit a ReleaseAuthorization Formto allow themselves toaccess the information of a particular person. When to require the DSHS 14-012(x) consent form. n3kGz=[==B0FX'+tG,}/Hh8mW2p[AiAN#8$X?AKHI{!7. %%EOF PDF Supplemental Nutrition Assistance Program (Snap) Authorized Log on to your account or contact your county office to update your information. Or, you may also limit duties. CF 37 (7/15) - Recertification For CalFresh Benefits. 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. Delete coded AREP information if you can'tconfirm with the client that it's still valid. Authorized Representatives for hearing purposes pursuant to . PDF Authorized Representative/ HIPAA Form - BenefitHelp Solutions endstream endobj 233 0 obj <> stream csf 14 authorization for release of information authorized representative The client can identify an AREP on the application, eligibility review form, or DSHS 14-532 authorized representative form. Cal program to send the CSF 14 to applicants/beneficiaries to appoint a Medi-Cal AR? N')].uJr 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. 102 0 obj <>stream EMC On-line Forms and Publications A - D - California Department of Social Choose My Signature. Purpose: 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. Clients must complete a DSHS 14-532 AREP form when designating a new AREP. 14-532 Authorized Representative Author: Brombacher, Millie A. Cal Fresh Forms + Resources San Diego Hunger Coalition 63-61 CalFresh Employment & Training Brochure, SAR 7 SAR 7 Eligibility Status Report Cambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, SAR 7 Addendum Instructions And Penalties SAR 7 Eligibility Status Report - For Cash Aid and CalFreshChinese,Farsi,Spanish, Tagalog,Vietnamese, SAR 7A How To Fill Out Your SAR 7 Eligibility Status ReportCambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, EBT 2216 EBT Surcharge Free Direct DepositHandout Cambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, PUB 13 Your Rights Under California Public Benefits Programs - For People ApplyingForOrReceiving Public AidInCaliforniaCambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, PUB 275 Family Planning- Making the Commitment for Healthy FutureCambodian, Chinese, Spanish,Vietnamese, PUB 524 Protect Your Benefit - Beware of Skims and Scans.
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