Form 6700-2026

1. Click ‘Get Form’ to open it in the editor.
2. In Section I, enter your name, Medicaid ID number (if known), and date of birth or Social Security number. Ensure all information is accurate for proper identification.
3. Proceed to Section II. Here, authorize the release of your Medicaid claims history by selecting one of the options in Part A. Specify if you want to release all information, only accident-related claims, or specific health care provider details.
4. In Part B, clearly state the purpose for releasing this information and set an expiration date for this authorization.
5. Sign in Part C and include the date. If signing on behalf of someone else, provide your authority on the designated line.
6. If necessary, have a witness sign below if the client cannot sign their name.

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