Healthcare Application For The Elderly And Disabled Page 10

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SFN 958 (3-2016)
Page 10 of 10
Authorization To Release Information
I/We authorize any person having custody or knowledge of the information relating to me or other household members to
disclose any requested information, including confidential information other than protected health information, to any
authorized agent of the North Dakota Department of Human Services. This authorization will remain valid until canceled in
writing or until coverage ends. I/We authorize Child Support to release any records of child support payments that I/we
have made or received. A copy of this authorization is as valid as the original.
Sign And Date The Application Here
Signature of Applicant:
Date:
Other Signature (Spouse, Guardian or Other Adult):
Date:

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