Dws-Esd 61app - Application For Food Stamps, Financial Assistance, Child Care, And Medical Assistance - 2014 Page 21
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29DWS-ESD 114AR
ATTACHMENT D
Rev. 07/2013
AUTHORIZATION TO DISCLOSE
MEDICAL ELIGIBILITY INFORMATION
__________________________ ___________________
____________
____/____/____
Customer Name
Social Security #
Case #
Date of Birth
D34314000242129
I _________________________________________________________hereby give
(Customer or Authorized Representative)
__________________________________________________________ the authority to:
(Name of Individual or Organization)
(check only one box)
Receive Medicaid, CHIP, UPP, PCN or Buyout eligibility information regarding my current application, ongoing case or a
recent case denial or closure. This authorization is effective from the date this form is signed to whichever of the following
occurs first:
The following date: __________________________; or
The medical application is denied*; or
30 days from the month the medical program is closed*.
*If the application is denied or the case is closed, information disclosure will continue throughout
the fair hearing process.
Speak or act on my behalf as an authorized representative, which includes receiving Medicaid, CHIP, UPP, PCN or Buyout
eligibility information regarding my current application, ongoing case or a recent case denial or closure. This authorization is
effective from the date this form is signed until a written notification to revoke the authorization is received by the Department of
Workforce Services.
_______________________________________________________________________________________
Address and Phone Number of Authorized Representative
I understand that I may revoke this authorization at any time by sending a written notification to the Department of Workforce Services
(DWS). I understand that a revocation is not effective to the extent that the Utah Department of Health, through its Division of Medicaid
and Health Financing (DMHF) or the DWS has relied on the disclosed health information.
I understand my rights and responsibilities described in the Notice of Privacy Practices. For a duplicate Notice of Privacy Practices,
access the following URL -
I understand that I may refuse to sign this authorization. I also understand that the DWS cannot deny eligibility for benefits if I
refuse to sign this authorization.
I understand that giving an individual authorized representative power allows them to act on my behalf, which includes making changes to
my medical case and any changes that they make, I may be liable for if an overpayment is incurred.
I understand that, once information is disclosed pursuant to this authorization, it is possible that it will no longer be protected by medical
privacy laws and could be disclosed by the person or agency that receives it.
Note: DMHF and DWS will not disclose controlled documents without the consent of their Legal Departments.
By signing this form, I acknowledge I have been provided a copy of this signed authorization.
_______________________________________________________/________________
Signature of Customer, Legal Guardian or Authorized Representative
Date
If signed by other than the customer; description of authority to serve: _____________________________________________________
_____________________________________________________________________________________________________________
Equal Opportunity Employer Program
Auxiliary aids and services are available upon request to individuals with disabilities by calling (801) 526-9240. Individuals
with speech and/or hearing impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162
Page 21
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