961 0 obj <> endobj EMC M. C 382 (6/18) Use this form to appoint an individual or organization as your Medi-Cal authorized representative. /Tx BMC Check the AREP information coded in ACES at each review. 16x;ltAx}0 /Tx BMC nQt}MA0alSx k&^>0|>_',G! endstream endobj 232 0 obj <> stream `% 4 li IIIIIIIIIKk*>>>A@)JRp(ig8`o0HRsMX"3@)E)mC]4l09zi%SK+__=>#v|) i Name . /%9TB!:(zQRN SSP 14 Authorization for Reimbursement of Interim AssistanceChinese, Spanish, 90-117 County of Alameda Lien FormSpanish, CW 2223 Demographic QuestionnaireChinese, Spanish, 50-123 EBT Card and PIN Responsibility Statement, 90-88 General Assistance Program - Health QuestionnaireSpanish, 90-151 Informed Consent for Health QuestionnaireChinese,Spanish, 90-251 CalFresh Employment & Training Program Option to Participate, 90-54 Important Notice to GA Applicants, SAR 7 SAR 7 Eligibility Status ReportCambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, PUB 13 Your Rights Under California Public Benefits Programs - For People ApplyingForOrReceiving Public AidInCaliforniaCambodian, Chinese, Farsi, Spanish, Tagalog, Vietnamese, YAE General Information Notice for the Young Adult Expansion Cambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, OAE General Information Notice for theOlderAdult Expansion Cambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, Alameda County Social Services Agency Home, CalWORKs Initial Application and Redetermination forms, CalFresh Initial Application and Renewal forms, General Assistance (GA) Initial Application and Renewal Application forms, Cash Assistance Program for Immigrants (CAPI) Initial Application forms. csf 14 authorization for release of information authorized representative. 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 77 0 obj <>/Encrypt 68 0 R/Filter/FlateDecode/ID[<7505846DAAB7146F6DCE917783904669><3A94F331270E8948AED6D6D48DFB54A6>]/Index[67 36]/Info 66 0 R/Length 64/Prev 84923/Root 69 0 R/Size 103/Type/XRef/W[1 2 1]>>stream 0 Authorization of Minors: If the patient is a minor (under 18 years of age) the authorization must be signed by a parent or legal guardian. Dental, Request for Access to Protected Health Information. pvphVwh h E^z8rn+>m>^#r^n/^_^Nsr#\rLL&I\R&4N8/` _%c endstream endobj 230 0 obj <> stream Form . PDF GOVERNMENT OF THE DISTRICT OF COLUMBIA - Washington, D.C. its regulations and Authorization Forms are common in the medical industry, especially if a patient is under a healthcare providers benefits. El asesor que se le asignar tendr una comunicacin directa desde el principio hasta el final de su gestin y entrega. 05/2018 CFSA - Authorization to Access and Disclose Mental Health or Substance Abuse Information Page 1 of 2 . # @`"PT {5@\jM+| sI 1B114F All Forms N/A Authorization for Release of Information Authorized Representative CSF 14 506481 Reason Code County Category NOA Action Document Name Number Template 300001 Placer Forms Affidavit to N/A Obtain Duplicate Warrant All 662 609763 300001 Santa Barbara Forms N/A Affidavit to Obtain Duplicate of Lost or 2y.-;!KZ ^i"L0- @8(r;q7Ly&Qq4j|9 PDF State of California Health and Human Services Agency Department of xc```c``#0``B]{20t8. 2020 (e) (7); 7 C.F.R. 2. p()md). C-761 Bay Area Consortium CAPI Transmittal, 50-85A Language Preference Form Cover Sheet (multi-language), 50-85 Language Preference Form (multi-language), C-134 Cash Assistance Program for Immigrants (CAPI) General Eligibility Information, Payment Levels and Reporting Responsibilities, 20-02 You May Be Required to Apply for SSI, SSP 14 Authorization for Reimbursement of Interim AssistanceChinese,Spanish, SOC 453 CAPI Statement of Household Expenses and ContributionsChinese,Spanish, SOC 455 CAPI State Interim Assistance Reimbursement AuthorizationChinese, Spanish, SOC 809 CAPI Indigence Exception StatementChinese, Spanish. 222 0 obj <> endobj 291 0 obj <>/Filter/FlateDecode/ID[('\315mre\3113.\033X\030>\fU\216\257) (Ruz\246o\3345M\225\321\256\261D\027\337\\)]/Index[222 70]/Info 219 0 R/Length 114/Prev 267957/Root 223 0 R/Size 292/Type/XRef/W[1 3 1]>> stream 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. DATE . "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 EBT 2259: Report of Electronic Theft of Benefits. 2y.-;!KZ ^i"L0- @8(r;q7Ly&Qq4j|9 . 886 0 obj <> endobj 936 0 obj <>/Filter/FlateDecode/ID[(\326\207Z2N\272\261I\266\305#\003b\307\005+) (\306o\226_\362i\tK\273\200\262\254> stream MCED Forms Spanish - California