These forms are in Adobe PDF format and you must have a copy of Adobe Acrobat Reader installed on your system to view them. 961 0 obj <> endobj The 14-012(x) is the correct form for authorizing the sharing of specified confidential information between specified parties for a specified period of time. Authorized Representatives for hearing purposes pursuant to . FCCH - Pre-Orientation Registration Information: Wait! To view a particular form, click on VIEW PDF the table below. 16x;ltAx}0 AD 4324 (2/21) - Adoption Questionnaire I This is a large PDF file. Box 12941, Oakland, CA 94604. %PDF-1.7 % 3013d100Hh>pY^?)~|P- 9& . The records of a students grades and transcript from the previous university will be disclosed with the aid of a Transcript Release Authorization Form. You may cancel or change this appointment at endstream endobj 897 0 obj <> stream The followingforms are informationalonlyanddo not need to bereturned to the county. PDF Authorized Representative/ HIPAA Form - BenefitHelp Solutions PDF Appointment of Authorized Representative Part A: Tell us about you Authorized Representative Name: Authorized Representative Address: Authorized Representative Telephone Number: I authorize the above designated individual to act as my representative for the purposes checked below. }3$@JAt " ]YL /@ > On-line Forms and Publications A - D - California Department of Social 29/06/2022 . n3kGz=[==B0FX'+tG,}/Hh8mW2p[AiAN#8$X?AKHI{!7. Forms and Brochures - California Department of Social Services endstream endobj 895 0 obj <>/Subtype/Form/Type/XObject>> stream 05/2018 CFSA - Authorization to Access and Disclose Mental Health or Substance Abuse Information Page 1 of 2 . The name, address, contact numbers, and date of birth are the common information found on this section. Appointment of Authorized Representative 1 . xc```c``#0``B]{20t8. 140 0 obj <> endobj \(DSHS ASD\) Subject: 14-532 Authorized Representative Keywords: DSHS 14-532 Authorized Representative Created Date: 6/21/2019 10:08:24 AM $uH-tH(CjGolH#6J0m0.&X}0Ls cWo { The following forms need to be completed during the application process. The DSHS 17-063 authorization form and the HCA 80-020 authorization for release of information form are HIPAA compliant forms designed for use by the client to authorize the release of existing documents to a specified individual or agency.
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