Form Mc 220 - Authorization For Release Of Information (Page 4 of 4) in pdf

State of California--Health and Human Services Agency

Department of Health Care Services

continued eligibility for, Medi-Cal based on disability. While giving us the information on

this form is voluntary, failure to provide all or part of the requested information could

prevent an accurate or timely decision on the named applicant’s application or on the

continuation of benefits. Although the information obtained with this form is not typically

used for any purpose other than making a determination of the applicant’s disability status,

such information may be disclosed by CDSS or DHCS for reasons related to the

administration of the Medi-Cal Program, such as, but not necessarily limited to: (1) to

enable a third party or agency to assist CDSS or DHCS in establishing rights to Medi-Cal

benefits, (2) to facilitate statistical research, audit activities and fraud and abuse

investigations/programs necessary to assure the integrity and improvement of the

Medi-Cal Program, and (3) in administrative and related legal proceedings involving your

appeal of a decision of the Medi-Cal Program. An individual has a right to access records

containing his/her personal information that are maintained by CDSS.

The official

responsible for maintaining the information is the Deputy Director of the Disability

Determination Service Division, 744 P Street, Sacramento, CA 95814, (916) 657-2265.

ATTENTION APPLICANTS/RECIPIENTS FOR CASH ASSISTANCE PROGRAM FOR

AGED, BLIND OR DISABLED IMMIGRANTS (CAPI)

In CAPI cases, in addition to the protection afforded to personal records by the Information

Practices Act, as discussed above, the documents and information collected based on this

authorization are subject to the protection accorded by Welfare and Institutions Code,

Section 10850, et. seq., but not that provided by Welfare and Institutions Code,

Section 14100.2 or other provisions applicable to the Medi-Cal Program.

In general,

Section 10850 forbids disclosure of lists of recipients on nonmedical public social services

such as CAPI, or other identifying information or personal information for any purpose not

connected with the administration of CAPI. The law authorizes the use of the records in

connection with investigation, auditing, and in administrative, civil and criminal proceedings

connected with CAPI program administration. The law also authorizes the sharing of such

information with other public agencies for the purposes of determining eligibility for and

other purposes connected with the administration of public social services, and with school

officials for the purposes of administering federally assisted programs providing cash

assistance or in-kind services directly to individuals based on need. Also, the law

authorizes disclosure of information for research purposes, provided that information

identifying the person who the records are about, is removed from the records. There is

also the possibility of disclosure pursuant to an order of a court of competent jurisdiction.

In reality, however, the kinds of records actually collected for the CAPI program based on

this authorization are likely to be used exclusively for determining disability, except where a

court orders disclosure for other purposes.

Page 4 of 4

MC 220 14 pt (04/08)

Form Mc 220 - Authorization For Release Of Information Page 4