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