Authorization To Disclose Information To Disability Determination Bureau (Ddb) (Page 2 of 2) in pdf

Explanation of Form F-14014

Disability Determination Bureau (DDB)

“Authorization to

”

We need your written authorization to get the information required to process your application for Medicaid Disability or Katie Beckett

Medicaid. Laws and regulations require that sources of personal information have a signed authorization before releasing it to the Disability

Determination Bureau (DDB). Also, laws require specific authorization for the release of information about certain conditions and from

educational sources.

You can provide this authorization by signing a Form F-14014. Federal law permits sources with information about you to release that

information if you sign a single authorization to release all your information from all your possible sources. We will make copies of it for each

source. If you sign such a single authorization, we will make copies of it for each source we contact to get your information. Some individual

sources of information may require a new signed authorization after you receive medical treatment. In those cases, we may ask you to sign

one authorization for each source and we may contact you again if we need you to sign more authorizations.

You have the right to revoke this authorization at any time, except to the extent a source of information has already relied on it to take an

action. To do so, make a written request to your county social or human services department, the Katie Beckett Program or directly to the

Disability Determination Bureau (P.O. Box 7886, Madison, WI 53707-7886). If you do, you should also send a copy of the request to revoke

to each of your sources of information. As described below, revocation could result in loss of entitlement.

IMPORTANT INFORMATION, INCLUDING NOTICE REQUIRED BY THE PRIVACY ACT

All personal information collected by the DDB is protected by the Federal Privacy Act of 1974. Once medical information is disclosed to the

DDB, it is no longer protected by the Health Insurance Portability and Accountability Act (HIPAA) health information privacy provisions (45

CFR part 164). The DDB retains personal information in strict adherence to the retention schedules established and maintained in

conjunction with the National Archives and Records Administration. At the end of a record’s useful life cycle, it is destroyed in accordance

with the privacy provisions, as specified in 36 CFR part 1228.

The DDB will use the information obtained with this form to determine your eligibility for benefits, and your ability to manage any benefits

received. This use usually includes review of the information by DDB staff in processing your case. In some cases, your information may

also be reviewed by DDB staff that process your appeal of a decision, or by investigators to resolve allegations of fraud or abuse, and may

be used in any related administrative, civil, or criminal proceedings.

Signing this form is voluntary, but failing to sign it, or revoking it before we receive necessary information, could prevent an

accurate or timely decision on your claim, and could result in denial or loss of benefits. Although the information we obtain with this

form is used for the purposes stated above and the information may be disclosed by the DDB without your consent if authorized by Federal

laws such as the Privacy Act and the Social Security Act. For example, the DDB may disclose:

To enable a third party (e.g., consulting physicians) or other government agency to assist the DDB to establish rights to Social

Security benefits and/or Medicaid coverage;

To comply with State and local laws requiring the release of information in situations of suspected child or elder abuse.;

We may also use the information you give us when we match records by computer. Matching programs compare our records with

those of other Federal, state, or local government agencies. Many agencies may use matching programs to find or prove that a

person qualifies for benefits paid by the government. The law allows us to do this even if you do not agree to it.

If You Need Assistance in Completing This Authorization or Have Questions

If you need assistance in completing this authorization or if you have questions about the authorization, please contact the Medicaid office

where you filed your application.

Form F-14014 (04/13) State of Wisconsin, Department of Health Services

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Authorization To Disclose Information To Disability Determination Bureau (Ddb) Page 2