CDSS forms and publications are available only in Portable Document Format (PDF). The authorized representative can do . AREPs are not automatically eligible to be an EBT Alternate Card Holder for Basic Food or cash benefits. The followingforms are informationalonlyanddo not need to bereturned to the county. Completing the DSHS 14-532 AREP form isn't required if the clientis confirming or making changes to their current AREP. Both the client and Alternate Card Holder must complete and sign the DSHS 27-130 form. El asesor que se le asignar tendr una comunicacin directa desde el principio hasta el final de su gestin y entrega. wG xR^[ochg`>b$*~ :Eb~,m,-,Y*6X[F=3Y~d tizf6~`{v.Ng#{}}jc1X6fm;'_9 r:8q:O:8uJqnv=MmR 4 endstream endobj 233 0 obj <> stream }@?@+br@rPRlimZ" sKOUZ}xdk!jB""d,EU$U}+b5 pBK 234 0 obj <> endobj EBT 2259: Report of Electronic Theft of Benefits. nQt}MA0alSx k&^>0|>_',G! H|n@,SEKlp5i"o93vtEew~iyL7{l4MW_jpymf_y>qli|?O]0w2GlH6tyW?wKYX~bcdo9gL[^KQ (m6 K%%@IX 0,00 . When to require the DSHS 14-012(x) consent form. CHECK ONE Patient Parent Domestic 2. The DSHS 14-532 authorized representative form shall be used when a client is authorizing an AREP at a time other than at application or eligibility review. For more information see Confidentiality and Public Disclosure. EMC An AREP can receive letters, including the income computation sheet, renewal forms, and ProviderOne services cards if the client has authorized the sharing of such correspondence. _gL7YG{b>v#F>//C1n taqOY__5UUeKZ\Uq2~?&Ymn J?4y/*Eue!~VUYTqZy?6u=gD Nx>mp ((J,8p Fh endstream endobj 897 0 obj <> stream nQt}MA0alSx k&^>0|>_',G! endstream endobj startxref 0 %%EOF 223 0 obj <>/Metadata 5 0 R/PageLabels 220 0 R/Pages 6 0 R/StructTreeRoot 17 0 R/Type/Catalog/ViewerPreferences<>>> endobj 289 0 obj <> stream PDF RELEASE OF INFORMATION - California Department of Social Services xcbd```b``V}`r5dXWd +D2)H "0012d[20j?cS&.@~{ h! Quieres probar una bsqueda? . State of California Department of Social Services Please refer to the Payees on Benefit Issuances - Authorized Representatives chapter, WAC 388-460-0005 through 460-0015 for AREP rules specific to the Basic Food (SNAP) program. "F$H:R!zFQd?r9\A&GrQhE]a4zBgE#H *B=0HIpp0MxJ$D1D, VKYdE"EI2EBGt4MzNr!YK ?%_&#(0J:EAiQ(()WT6U@P+!~mDe!hh/']B/?a0nhF!X8kc&5S6lIa2cKMA!E#dV(kel }}Cq9 . An AREP may receive letters/notices/forms/warrants/EFT/ProviderOne service cards or they may have permission to only discuss the case and not receive any written correspondence. Check the AREP information coded in ACES at each review. Problems with downloading forms? APPOINTMENT OF REPRESENTATIVE. AD 100A (7/20) - Authorization For Release, Use And/Or Disclosure Of Health Information AD 165 (3/15) - Presumed Father's Consent To Adoption When Denying He Is The Biological Father (In Or Out-Of-California) - Independent Adoptions Program TO BE COMPLETED BY APPLICANT / BENEFICIARY . Authorized Representative/ HIPAA Form PLEASE PRINT CLEARLY * This information is mandatory. 166 0 obj <>/Encrypt 141 0 R/Filter/FlateDecode/ID[<7D6D17A302C5ACFD3A69D63CA072DE31><93B97E192985F34987B8D519A2DF3746>]/Index[140 61]/Info 139 0 R/Length 97/Prev 26174/Root 142 0 R/Size 201/Type/XRef/W[1 2 1]>>stream Dental, Request for Access to Protected Health Information. /Tx BMC PDF fill and print forms may be completed online and printed to hardcopy to be signed and mailed in or submitted in person to an eligibility worker for processing. HTP=o ',V58)RC!C}MH g?=FoaF3i uP`{zT8u8@JsaSu+n7"k03h-.+AA5t2/+Rz3>&3n'!0N-@0 NiA@}n9r?%#
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