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ES 3904 6/17-2026
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- Click ‘Get Form’ to open the ES 3904 6/17 in the editor.
- Begin by entering your Social Security Number (SSN) and full name, including first, middle, and last names, along with your date of birth in the specified format (mm/dd/yy).
- In the section labeled 'WHOSE Records to be Disclosed', clearly indicate all medical and psychological sources from which you are requesting records.
- Provide detailed information about the purpose of this authorization. Specify that it is for determining eligibility for medical assistance.
- Sign the form where indicated, specifying your authority to sign as either self or guardian/parent. Include any necessary documentation if applicable.
- Fill in your contact details including street address, phone number, city, and ZIP code.
- If required, have a witness sign the form to confirm identity if you signed with an 'X'.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2017 | 4.7 Satisfied (59 Votes) |
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