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Title 22 of the . MC 018 Medi-Cal Information for Applicants (multi-language), POP Parentage Opportunity Program Brochure, GEN 1365 Notice of Language Services (Multi-language), YAE General Information Notice for the Young Adult ExpansionCambodian, Chinese, Farsi, Spanish, Tagalog,Vietnamese, OAE General Information Notice for theOlderAdult ExpansionCambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, MC 003 Medi-Cal Services for Children and Young Adults: EPSDTCambodian, Chinese, Farsi, Spanish, Tagalog, Vietnamese, MC 020 Notice to Beneficiaries Regarding IRS Form 1095-BSpanish, MC 219 Important Information for Persons Requesting Medi-CalCambodian, Chinese, Farsi, Spanish, Tagalog, Vietnamese, MC 372 Breast and Cervical Cancer Treatment Program (BCCTP)Cambodian, Chinese, Farsi, Spanish, Tagalog,Vietnamese, MC 007 Medi-Cal General Property Limitations, DHCS 7077 Notice Regarding Transfer of a Home for both a Married and an Unmarried Applicant/BeneficiarySpanish, DHCS 7077A Notice Regarding Transfer of a Home for both a Married and an Unmarried Applicant/Beneficiary, PUB 13 Your Rights Under California Public Benefits Programs - For People ApplyingForOrReceiving Public AidInCaliforniaCambodian, Chinese, Farsi, Spanish, Tagalog, Vietnamese, PUB 68 My Medi-Cal: How to Get the Health Care You NeedCambodian, Chinese, Farsi, Spanish, Tagalog, Vietnamese, PUB 183 Medical and Dental Health Check-ups CHDP BrochureSpanish, 910169 California Families Grow Healthy with WIC brochureSpanish. See the Authorized Representative Payee Chart.
EMC 05/2018 CFSA - Authorization to Access and Disclose Mental Health or Substance Abuse Information Page 1 of 2 . This form authorizes the release of medical information to the representative . Medical professionals, financing agents, employers, and even faculty members need to submit a ReleaseAuthorization Formto allow themselves toaccess the information of a particular person. xc``a``b```a@@1CD'{> %k( Case number (optional) Date . When it's permissible to share information without consent. endstream
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Record the representative's name and address on the AREP screen in ACES. C. del Doce de Octubre, 24, local 7, 28009 Madrid, Apostillado documentos del Registro Civil, Apostillado documentos para trabajar en el Extranjero, Apostillado de Documentos emitidos en Registro Civil, Apostilla de documentos para trabajar en el Extranjero. The Public Disclosure Unit is responsible for approving or denying requests for disclosure of confidential information. There are three variants; a typed, drawn or uploaded signature. This chapter defines an authorized representative (AREP) and provides instruction on: What form to use in order to code someone in ACES or the ECR as an AREP. pvphVwh h E^z8rn+>m>^#r^n/^_^Nsr#\rLL&I\R&4N8/` _%c la persona asignada para el proceso de legalizacin en los distintos Ministerios, Cmaras, Consulados y Organismo Oficiales que requiera, con ms de 20 aos de experiencia Contamos tambin con traductores Jurados reconocidos por el Ministerio de Asuntos Exteriores, 2022 Apostilladodelahaya.comTodos los derechos reservados, 2022 Apostilladodelahaya.com Todos los derechos reservados. p()md). /Tx BMC fSZHti>DB6O,? 2y.-;!KZ ^i"L0-
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PDF GOVERNMENT OF THE DISTRICT OF COLUMBIA - Washington, D.C. I understand that if I do not check any of the boxes below, my authorized representative will be authorized to perform all of the . The patients parents will have to sign the form and indicate that they allow the guardian to take care of their child. Authorized Representatives for hearing purposes pursuant to . El asesor que se le asignar tendr una comunicacin directa desde el principio hasta el final de su gestin y entrega.La persona asignada para el proceso de Apostilla en los distintos Ministerios, Cmaras, Colegios y Organismo Oficiales que requiera, con ms de 20 aos de experiencia Contamos tambin con traductores Jurados reconocidos por el Ministerio de Asuntos Exteriores, Nuestro personal est altamente cualificado. A Financial Authorization Form is also used by business men in allowing their trusted representatives to transact an amount on their behalf. AUTHORIZED REPRESENTATIVE,20. I understand that if I do not check any of the boxes below, my authorized representative will be authorized to perform all of the . AREPs are not automatically eligible to be an EBT Alternate Card Holder for Basic Food or cash benefits. The REP Type code on the AREP screen determines what forms, letters, etc. Estate Recovery Forms. /Tx BMC endstream
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x,O Student Financial Aid Verification CSF 50 (English and Spanish) Additional Forms. HIPAA restrictions prevent us from discussing the client's individual health information with an AREP unless a current signed DSHS 14-012(x) consent form is in the record. Problems with downloading forms? %=coF5H_}{AWwEPY]1BE8=mF~tU3PI3=^mdHCgIsME>5s4Y|hhBo(cHivU.-KGr0h_i9R
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Forms By Name | A - California 63-57 CalFresh Application Cover Sheet (multi-language), CW 2223 Demographic QuestionnaireChinese, Spanish, 50-110 Voter Preference FormCambodian, Chinese, Farsi, Spanish, Tagalog,Vietnamese. Here's How, CW 2166 (11/21) - Multilingual Work Really Pays! CalFresh Application CF 285 (English) Dual Application SAWS2Plus . @ $0X + csf 14 authorization for release of information authorized representative. Document extensions or changes to the designated AREP in ACES. 63-61 CalFresh Employment & Training Brochure, SAR 7 SAR 7 Eligibility Status Report Cambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, SAR 7 Addendum Instructions And Penalties SAR 7 Eligibility Status Report - For Cash Aid and CalFreshChinese,Farsi,Spanish, Tagalog,Vietnamese, SAR 7A How To Fill Out Your SAR 7 Eligibility Status ReportCambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, EBT 2216 EBT Surcharge Free Direct DepositHandout Cambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, PUB 13 Your Rights Under California Public Benefits Programs - For People ApplyingForOrReceiving Public AidInCaliforniaCambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, PUB 275 Family Planning- Making the Commitment for Healthy FutureCambodian, Chinese, Spanish,Vietnamese, PUB 524 Protect Your Benefit - Beware of Skims and Scans. endstream
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stream The Alameda County Social Services Agency provides resources and opportunities in a culturally responsive manner to enhance the quality of life in our community by protecting, educating, and empowering individuals and families. information without appointing an AR using a written authorization, such as a "Release of Information" form, or a telephonic authorization. Hj`@
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Form . These forms allow the disclosure of a designated set of records from the individual's DSHS or HCA file.
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stream hbbd```b``N?9d fHz0iL"``,~H2jU'@d!H#Yh? Both the client and Alternate Card Holder must complete and sign the DSHS 27-130 form. Follow this simple instruction to edit California calfresh authorization online in PDF format online for free: . Tips for Using Adobe PDF Files, Chinese Forms beginning with letters N through Z, A | B | C | D | E | F | G | H | I | J | K | L | M, Copyright 2023 California Department of Social Services, AAP 1 (11/22) - Request For Adoption Assistance Program Benefit, AAP 3 (2/22) - Reassessment Information - Adoption Assistance Program, AAP 5 (9/18) - Adoptions Assistance Program Independent Adoptions Program, AAP 6 (11/22) - Adoption Assistance Program Negotiated Benefit Amount and Approval, AAP 7 (12/17) - Adoptions Assistance Program Statement Of Acknowledgement, AAP 8 (9/18) - Adoption Assistance Program Nonrecurring Adoption Expenses Agreement, AAP 9A (5/21) -Adoption Assistance Program (AAP)Level Of Care Rate Determination Protocol Matrix, AAP 10 (10/21) -Prospective Or Adoptive Parent(s) Level Of Care (LOC) Reporting Tool, ABCD 239.7A (8/01) - Notice Of Administrative Disqualification California Work Opportunity And Responsibility To Kids (CalWORKs) Program, ABCD 478A (5/20) - Disqualification Consent Agreement California Work Opportunity And Responsibility To Kids (CalWORKs) Program, AD 1A (4/22) - Parental Consent To Adoption(In Or Out-Of-California), AD 65 (2/02) - Parent's Authorization For Medical And Surgical Care, AD 67 (5/15) - Information About The Birth Mother - Agency And Independent Adoptions Program, AD 67A (7/15) - Information About The Birth Father - Agency And Independent Adoptions Program, AD 100 (9/22) - Authorization For Release, Use And/Or Disclosure Of Health And Other Information - Agency And Independent Adoption Programs, AD 501 (6/14) - Relinquishment In or Out-of-County (Birth Mother/Biological Father/Presumed Father In California), AD 501A (9/14) - Relinquishment Out-of-State (Birth Mother/Biological Father/Presumed Father) (ENG/CH), AD 508 (7/13) - Rescission Request/Rescission Of Relinquishment, AD 512 (1/14) - Psychosocial And Medical History Of Child, AD 586 (7/14) - Relinquishment In or Out-of-County (Alleged Natural Father In California), AD 590 (4/15) - Waiver Of Right To Further Notice Of Adoption Planning (Alleged Father In Or Out Of California) - Agency And Independent Adoptions Program, AD 590A (6/15) - Waiver Of Right To Further Notice Of Adoption Planning - Presumed Father In Or Out Of California - Agency And Independent Adoptions Program, AD 591 (12/14) - Relinquishment - Out-of-State (Alleged Natural Father), AD 880 (2/21) Declaration Of Birth Parent - Agency And Independent Adoptions Program, AD 885 (3/14) - Mother Or A Biological/Presumed Father Of A Child Who Is Not Detained, A Juvenile Court Dependent In Out-of-home Care, Or The Ward Of A Legal Guardian, AD 885C (2/15) - Statement of Understanding Agency Adoptions Program - Alleged Natural Father Of The Child Who Is Not Detained, A Juvenile Court Dependent In Out-Of-Home Care, Or The Ward Of A Legal Guardian, AD 887 (3/18) - Statement Of Understanding Independent Adoptions Program - Parent Who Gave Physical Custody (Custodial Parent) Of The Child To The Petitioner(s), AD 887A (3/18) - Statement Of Understanding Independent Adoptions Program - Parent Who Did Not Give Physical Custody (Non-Custodial Parent) Of The Child To The Petitioner(s), AD 902 (2/22) - Consent For Arranging Contact, AD 908 (5/22) - Adoptions Information Act Statement, AD 918 (11/03) - Family Assessment Questionnaire II, AD 924 (5/15) - Independent Adoption Placement Agreement - Independent Adoptions Program, AD 926 (4/14) - Statement Of Understanding Independent Adoptions Program Parent Who Places The Child With The Prospective Adoptive Parent(s) - Independent Adoptions Program, AD 928 (7/02) - Revocation Of Consent Independent Adoption Program, AD 929 (8/11) - Waiver Of Right To Revoke Consent Independent Adoption Program, AD 931 (2/20) - Independent Adoption Of A Foreign-Born Child - Statement Of Acknowledgment, AD 933 (12/20) - Intercountry Readoption Acknowledgment, AD 4320 (6/22) - Adoption Assistance Program (AAP) Agreement, AD 4324 (2/21) - Adoption Questionnaire I, AD 4337 (10/21) - Criminal Record Statemen, AR 2 (11/13) - Reporting Changes For CalWORKs And CalFresh, AR 2 SAR (3/15) - Reporting Changes For CalWORKs And CalFresh, AR 3 (2/15) - Mid-Year Status Report For CalWORKs And CalFresh, ARC 1 (4/22) - Statement Of Facts Supporting Eligibility For The Approved Relative Caregiver (ARC) Funding Option Program, ARC 1A (11/16) Rights, Responsibilities, And Other Important Information, ARC 2 (11/16) - Redetermination: Statement Of Facts Supporting Eligibility For The Approved, CCP 1 (3/15) - Declaration of Exemption from Trustline Registration and Health and Safety Self-Certification, CCP 4 (8/21) - Health And Safety Self-Certification (For license-exempt providers), CCP 6 (8/99) - Health And Safety Checklist, CCP 7 (10/19) - CalWORKs Child Care Request Form And Child Care Payment Rules, CCP 8 (10/19) - CalWORKs Stage One Child Care Authorization Form, CCP 2145 (5/04) - CalWORKs Child Care Reimbursement Report, CF 1 (10/14) - Notice To All CalFresh Recipients - Important Please Read, CF 10 (12/13) - Dependent Care Cost Affidavit, CF 11 (9/21) - Notice To All CalFresh Recipients, CF 11 (9/22) - Notice To All CalFresh Recipients, CF 18 (2/14) ENG/Chinese - Important Information, CF 20 (2/14) - You Do Not Owe Anything For Receiving CalFresh Benefits, CF 28 Coversheet (2/14) - CalFresh Program Restricted Account Coversheet - Important To Know, CF 28A (2/14) - CalFresh Program Restricted Account Agreement Part A, CF 28B (2/14) - CalFresh Program Restricted Accounting Agreement part B, CF 29 (10/13) - CalFresh Recertification Appointment Letter, CF 29A (2/14) - CalFresh Initial Appointment Letter, CF 29B (2/14) - CalFresh Initial On-Demand Appointment Letter, CF 29C (2/14) - CalFresh Recertification Appointment Letter, CF 29D (2/14) - CalFresh Recertification On-Demand Appointment Letter, CF 31 (6/19) - CalFresh Supplemental Form For Special Medical Deductions, CF 32 (6/13) - CalFresh Request For Contact, CF 34 (12/20) CalFresh Notice of Change: Semi-Annual Reporting Eliminated, CF 37 (11/16) - Recertification For CalFresh Benefits, CF 100 (11/20) - CalFresh Request For Authorized Representative Drug Or Alcohol Treatment Center Resident, CF 101 (11/20) - CalFresh Request For Authorized Representative, CF 285 (4/21) - Application For CalFresh Benefits, CF 285LP (4/21) - Application For CalFresh Benefits, CF 285A (11/21) - Application For CalFresh Benefits, CF 303 (8/19) Replacement Or Disaster Supplement Affidavit, CF 377.1 (5/20) - Notice Of Approval For CalFresh Benefits, CF 377.1LP (5/20) - Notice Of Approval For CalFresh Benefits, 377.1A (8/21) - Notice Of Denial Or Pending Status, CF 377.1A LP (8/21) - Notice Of Denial Or Pending Status, CF 377.11 (6/18) - CalFresh Time Limit Notice - Failure To Meet The Able-Bodied Adults Without Dependents (ABAWDs) Work Requirement, CF 377.11A (6/18) - CalFresh Time Limit Notice - Expiration Of Three Consecutive Months For Able-Bodied Adults Without Dependents (ABAWDs), CF 377.11B (6/18) - CalFresh Countable Month Letter - Use Of Countable Month For Able-Bodied Adults Without Dependents (ABAWDs), CF 377.11C (1/20) - CalFresh Informational Notice - CalFresh Time Limit For Able-Bodied Adults without Dependents (ABAWDs), CF 377.11D (1/20) CalFresh Discretionary Exemption For Able-Bodied Adults Without Dependents (ABAWDs), CF 377.11E (1/20) CalFresh Able-Bodied Adult Without Dependents (ABAWD) Time Limit Exemption Screening Form, CF 377.2 (9/18) - CalFresh Notice Of Expiration Of Certification, CF 377.2B (12/20) - CalFresh Notice Of Expiration Of Certification For Households With Only Elderly And/Or Disabled Members, CF 377.2C (12/20) - CalFresh Notice Of Expiration Of Certification For Households With Only Elderly And/Or Disabled Members, CF 377.2D (3/18) - CalFresh Notice Of Status Change For Households With Only Elderly And/Or Disabled Members, CF 377.4 CR (1/14) - CalFresh Notice Of Change For Change Reporting Households, CF 377.4 SAR (6/13) - CalFresh Notice Of Change For Semi-Annual Reporting Households, CF 377.4A (2/14) - CalFresh Notice Of Change (Non-Citizen), CF 377.5 SAR (9/13) - CalFresh Mid-Certification Period Status Report, CF 377.6 (8/13) - Information/Verification Needed, CF 377.7A (2/14) - Notice Of Administrative Disqualification, CF 377.7A1 (2/14) - Request For Restoration Of CalFresh Benefits After Administrative Disqualification, CF 377.7B (4/18) - CalFresh Overissuance Notice - Inadvertent Household Errors (IHE) Only, CF 377.7B LP (2/18) - CalFresh Overissuance Notice - Inadvertent Household Errors (IHE) Only, CF 377.7B1 (10/17) - CalFresh Repayment Notice For Inadvertent Household Errors Only Final Notice, CF 377.7B1 LP (2/18) - CalFresh Repayment Notice - Inadvertent Household Errors Only Final Notice, CF 377.7C (2/14) - CalFresh Repayment Agreement For Inadvertent Household Errors Only, CF 377.7D (1/14) - CalFresh Overissuance Notice For Administrative Errors (AE) Only, CF 377.7D1 (1/14) - CalFresh Overissuance Notice For Administrative Errors (AE) Only, CF 377.7D2 (10/17) - CalFresh Repayment Final Notice - County Administrative Error (AE), CF 377.7D2 LP (2/18) - CalFresh Repayment Final Notice - County Administrative Error (AE), CF 377.7D3 (10/17) - CalFresh Overissuance Notice For Administrative Errors (AE), CF 377.7D3 LP (6/18) - CalFresh Overissuance Notice For Administrative Errors (AE), CF 377.7E1 (1/14) - CalFresh Repayment Agreement For Administrative Errors Only, CF 377.7F (10/17) - CalFresh Overissuance Notice - Change From Inadvertent Household Error (IHE) To Intentional Program Violation (IPV), CF 377.7F1 (10/17) - CalFresh Repayment Final Notice - Intentional Program Violation (IPV), CF 377.7F1 LP (2/18) - CalFresh Repayment Final Notice - Intentional Program Violation (IPV), CF 377.7G (3/18) - CalFresh Intentional Program Violation (IPV) Notice - Due To Trafficking, CF 377.7H (2/23) - CalFresh Informational Notice - Potential Intentional Program Violation (IPV), CF 377.9 (8/20) - Notice Of Back CalFresh Benefits, CF 377.9LP (8/20) - Notice Of Back CalFresh Benefits, CF 385 (10/15) - Application For Disaster CalFresh, CF 386 (2/14) - CalFresh Notice Of Missed Interview, CF 387 (5/14) - CalFresh Request For Information, CF 388 (8/13) - CalFresh Notice Of Restoration Approval, CF 389 (2/14) - Notice Of Denial Of Restoration, CF 478 (2/14) - Disqualifiction Consent Agreement CalFresh Program, CF 886 (8/22) - CalFresh Notice Of Work Rules, CF 1239 (12/20) - CalFresh Notice Of Approval/Denial/Termination Transitional Benefits, CF 6177 (10/22) - CalFresh Student Exemption Screening Form, CF SSA 1 (8/21) - Information For Households Applying For CalFresh With The Social Security Administration, CF SSA 1LP (9/20) - Information For Households Applying For CalFresh With The Social Security Administration, CL 1 (4/99) - Cal-Learn Registration Program Information Orientation Appointment, CL 2 (4/99) - Cal-Learn PROGRAM REQUIREMENTS, CL 3 (4/99) - Cal-Learn Notice Of A Participation Problem, CL 4 (4/99) - Cal-Learn Notice To Parent/Legal Guardian Of Cal-Learn Participant, CL 8 (3/99) - Cal-Learn Notice Of Report Card Submittal Schedule, CL 9 (3/99) - Cal-Learn Notice Of Good Cause Determination, CL 10 (4/99) - Cal-Learn Notice Of Exemption/Deferral, CL 11 (4/99) - Cal-Learn Notice Of Incomplete Grades, CR 6181 (11/20) - Interpreter Services Statement And Confidentiality Agreement, CSFP 001 (7/22) - Commodity Supplemental Food Program (CSFP) Participant Application, CSFP 006 (7/22) - Commodity Supplemental Food Program (CSFP) Notice Of Action, CTRI 01 (10/20) - California Tax Return Information (CTRI) Notification To Client, CW 2.1 N A (8/04) - Notice And Agreement For Child, Spousal And Medical Support, CW 4 (6/02) - Immediate Need Payment Request, CW 5 (7/02) - Veterans Benefits Verification and Referral, CW 8 (11/14) - Statement Of Facts For An Additional Person, CW 8A (12/14) - Statement Of Facts To Add A Child Under 16, CW 10 (7/01) - Notice of Withdrawn Application, CW 13 (9/02) - Caretaker Relative Agreement, CW 23 (3/00) - Senior Parent - Statement Of Facts, CW 25 (7/01) - Supplemental Statement Of Facts - Minor Parent, CW 25A (2/13) - Payee Agreement For Minor Parent, CW 42 (10/21) - Statement of Facts - Homeless Assistance, CW 43 (3/00) - CalWORKs Applicant Choice Form Immediate Need Payment/Expedited Grant, CW 51 (10/11) - Child Support - Good Cause Claim For Noncooperation, CW 52 (7/18) - Changes To The California Work Opportunity And Responsibility To Kids (CalWORKs) Assistance Unit And Child Support Rules, CW 52 (10/20) California Work Opportunity And Responsibility To Kids (CalWORKs) Child Support Instead Of Cash Grant Option, CW 60 (5/01) - Release Of Information - Financial Institution, CW 61 (7/01) - Authorization to Release Medical Information, CW 63 (11/20) - Request For Income And/Or Resource Verification, CW 71 (3/00) - Statement Of Cash Aid Mother And Unrelated Adult Male (UAM), CW 74 (9/19) - Permanent Housing Search Document, CW 80 (2/18) - Self-Certification Form For Motor Vehicles - CalWORKs, CW 82 (3/00) - Important Information About This Agreement, CW 86 (10/21) - Agreement - Restricted Account California Work Opportunity And Responsibility To Kids (CalWORKs) Program, CW 87 (6/02) - Reinforming Letter/Add a Person(s) Program, CW 88 (6/11) - Diversion Services Agreement CalWORKs Program, CW 88 Coversheet (6/11) - You May Be Eligible For Diversion Services, CW 89 (2/03) - Application Withdrawl Request, CW 101 (7/17) - CalWORKs Immunization Rules, CW 103 (11/09) - Multilingual - Transitional Medi-Cal, CW 377 (2/23) - CalWORKs Informational Notice - Potential Intentional Program Violation (IPV), CW 2103 (6/16) - Reminder For Teens Turning 18 Years Old, CW 2166 (12/20) - Multilingual Work Really Pays!