ES 3904 6/17-2026

1. Click ‘Get Form’ to open the ES 3904 6/17 in the editor.
2. 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).
3. In the section labeled 'WHOSE Records to be Disclosed', clearly indicate all medical and psychological sources from which you are requesting records.
4. Provide detailed information about the purpose of this authorization. Specify that it is for determining eligibility for medical assistance.
5. Sign the form where indicated, specifying your authority to sign as either self or guardian/parent. Include any necessary documentation if applicable.
6. Fill in your contact details including street address, phone number, city, and ZIP code.
7. If required, have a witness sign the form to confirm identity if you signed with an 'X'.

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