General Consent/Authorization for Release of Information
Office Use Only
CASE NUMBER
To be completed by the person giving consent/authorizing release of information (please print): We ask for this information only to verify your identity and to locate your data.
NAME
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DATE OF BIRTH (MM/DD/YYYY)
-
Month
-
Day
Year
Date
SOCIAL SECURITY NUMBER
If you get SNAP, cash assistance, health care or child support services, or are a license holder, please provide at least one of these numbers:
MEMBER ID NUMBER (PERSON MASTER INDEX [PMI] NUMBER)
NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER
SINGLE MEMBER INDEX (SMI) NUMBER
FAMILY DAY CARE LICENSE NUMBER
FOSTER CARE LICENSE NUMBER
Authorization/Consent: I authorize the Minnesota Department of Human Services ("DHS") to release the following information about me: (Must be completed)
*
NAME
*
First Name
Last Name
COMPANY OR AGENCY
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PHONE NUMBER
Format: (000) 000-0000.
The information will be used for: (Must be completed)
*
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Consequences: I know:
state and federal privacy laws protect my records;
why I am being asked to release this information or that this authorization is made at my request;
signing this authorization will not affect my treatment, payment, enrollment or eligibility for benefits;
that, generally, I must give my written consent for DHS to give out the information;
that if I do not consent, the information will not be released unless the law otherwise allows it;
I may stop this consent with a written notice to DHS at any time, but this written notice will not affect information DHS has already released;
My right to stop this authorization may be limited by exceptions stated in DHS' Notice of Privacy Practices, which may be found on the DHS public website;
that the person or agency that gets my information may be able to pass it on to others;
that if DHS passes my information on to others, it may no longer be protected by this authorization; and
that this authorization ends one year from the date I sign it, unless the law allows for a longer period.
CLIENT SIGNATURE
DATE
-
Month
-
Day
Year
Date
OR
SIGNATURE OF PARENT/GUARDIAN/AUTHORIZED REPRESENTATIVE
DATE
-
Month
-
Day
Year
Date
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800-657-3672 or 651-297-3862
Attention. If you need free help interpreting this document, call the above number.
ያስተውሉ፡ ካለምንም ክፍያ ይህንን ዶኩመንት የሚተረጉምሎ አስተርጓሚ ከፈለጉ ከላይ ወደተጻፈው የስልክ ቁጥር ይደውሉ፡፡
ملاحظة: إذا أردت مساعدة مجانية لترجمة هذه الوثيقة، اتصل على الرقم أعلاه.
သတိ။ ဤစာရက်စာတမ်းအားအခမဲ့ဘာသာပြန်ပေးခြင်း အကူအညီလိုအပ်ပါက၊ အထက်ပါဖုန်းနံပါတ်ကိုခေါ်ဆိုပါ။
កំណត់សំគាល់ ។ បើអ្នកត្រូវការជំនួយក្នុងការបកប្រែឯកសារនេះដោយឥតគិតថ្លៃ សូមហៅទូរស័ព្ទតាមលេខខាងលើ ។
請注意,如果您需要免費協助傳譯這份文件,請撥打上面的電話號碼。
Attention. Si vous avez besoin d'une aide gratuite pour interpréter le présent document, veuillez appeler au numéro ci-dessus.
Thov ua twb zoo nyeem. Yog hais tias koj xav tau kev pab txhais lus rau tsab ntaub ntawv no pub dawb, ces hu rau tus najnpawb xov tooj saum toj no.
ဟ်သူဉ်ဟ်သးဘဉ်တ.ဖဲနလိဉ်ဘဉ်မၤစၤကလီလ၊တ၊်ကကျိုးထံဝဲစဉ်လံာ်တီလံာ်မီတခါအံၤနာ်.ကိးဘဉ်လီတ်စိနီ၊်လ၊ထူးအံဉ်တ
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ໂປຣດຊາບ. ຖ້າຫາກ ທ່ານຕ້ອງການການຊ່ວຍເຫຼືອໃນການແປເອກະສານນີ້ຟຣີ, ຈົ່ງໂທຣໄປທີ່ໝາຍເລກຂ້າງເທີງນີ້.
Hubachiisa. Dokumentiin kun tola akka siif hiikamu gargaarsa hoo feete, lakkoobsa gubbatti kenname bilbili.
Внимание: если вам нужна бесплатная помощь в устном переводе данного документа, позвоните по указанному выше телефону.
Digniin Haddii aad u baahantahay caawimaad lacag-la'aan ah ee tarjumaadda (afcelinta) qoraalkan, lambarka kore wac.
Atención. Si desea recibir asistencia gratuita para interpretar este documento, llame al número indicado arriba.
Chú ý. Nếu quý vị cần được giúp đỡ dịch tài liệu này miễn phí, xin gọi số bên trên.
For accessible formats of this information or assistance with additional equal access to human services, write to DHS.info@state.mn.us, call 800-657-3672, or use your preferred relay service. ADA1 (2-18)
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