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Verification of benefits dpss

PURPOSE OF THIS FORM: This form asks you to ... - DPSS 2026

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The document is an Authorization for Use and Disclosure of Protected Health Information form from the County of Los Angeles Department of Public Social Services (DPSS). It allows individuals to consent to share their health information with DPSS for the purpose of determining eligibility for benefits. The form outlines the rights of the individual, including the ability to revoke consent at any time, and specifies what health information can be shared.

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How to use or fill out PURPOSE OF THIS FORM: This form asks you to agree to allow DPSS to access your health information

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Click ‘Get Form’ to open it in the editor.
Begin by entering the date at the top of the form, followed by your case name and case number.
Fill in your worker's name, ID, and phone number, along with your customer ID.
Provide your last name, first name, and date of birth in the designated fields.
In the authorization section, specify the facility name and its address where your health information will be released from.
Indicate which information can be released by checking the appropriate boxes related to mental conditions or other specified details.
Sign and date the form at the bottom. Ensure a witness also signs if required.
If you change your mind later, follow the instructions for revocation provided at the end of the form.

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Versions	Form popularity	Fillable & printable
2017	4.8 Satisfied (86 Votes)
2015	4.2 Satisfied (46 Votes)

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