Form Dss-6969 - Consent For Release Of Information - North Carolina Economic And Family Services

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CONSENT FOR RELEASE OF INFORMATION
__________________ COUNTY DEPARTMENT OF SOCIAL SERVICES
Privacy Statement: Providing your social security number is voluntary. However, you may be required to
sign consent for the release of information if needed to make a determination about your eligibility for benefits
and services. Federal and State laws require health and human services agencies to protect the privacy and
security of applicant/recipient information. Information released to another entity may potentially be shared
with another agency, in which case state or federal law may not protect the information.
.
Please read this form carefully, and ask questions if you do not understand
:
)
Date of Birth:
Name of Applicant/Recipient
SSN
(optional
(Last, First, Middle Initial)
Street Address:
City:
:
:
State
Zip code
1. I Authorize: (Name of Person/Agency)
Street Address:
City:
State:
Zip Code:
2. To Release Information to: (Name of Person/Agency to receive information)
Street Address:
City:
State:
Zip Code:
3.
The following information: (Be Specific)
4.
The information identified above will be used for: (list each purpose)
5.
This authorization remains in effect until: (up to a maximum period of one year)
DSS-6969 (rev. 01-13)
Economic and Family Services

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