Instructions

Medical Assistance Authorization to Furnish/Release Information

Medical Assistance applicants must fill out this form at the time of application or when a new adult household member enters the home.

This form allows the Department of Social Services to obtain necessary verifications from other agencies. It authorizes these other agencies to release information to the department.

• Once you have completed this form, submit it to your local Department of Social Services office. If you have a question about this form, contact your local Department of Social Services office.