Healthcare TANF Forms

HEALTHCARE TANF FORMS

Applicant / Patient Information

Patient Name:

Female    Male    Other    Prefer not to say

Household & TANF Case Information

Do you currently receive TANF benefits?    Yes    No

Other public benefits received (check all that apply):
SNAP / Food Assistance    Medicaid / Medical Assistance    Unemployment    None of the above

Insurance Information

Medical History & Current Health

Emergency Contact

Authorization for Release of Medical Information to TANF

I authorize the release of my medical information, including medical records, treatment notes, diagnostic results, billing information, and eligibility-related documentation to my TANF caseworker and the authorized representatives of the TANF agency for the purpose of benefit determination, case management, care coordination, and verification of services. This authorization includes disclosure of mental health and substance use treatment records as necessary for TANF eligibility and services, except where restricted by law.

Recipient to receive information: TANF caseworker, TANF program staff, and their designees. Records to be released: all medical records relevant to TANF eligibility and services as described above.

I understand that I may revoke this authorization at any time by delivering a written revocation to the releasing health care provider, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures already made in reliance on this authorization prior to receipt of the revocation.

HIPAA Acknowledgment & Privacy

I acknowledge receipt of the facility's Notice of Privacy Practices and understand that health information used or disclosed under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations. I understand this authorization is voluntary and that refusal to sign will not affect my ability to obtain treatment, payment, or eligibility for benefits, except where disclosure is required to determine TANF eligibility.

I further certify that the information provided on this form is true and complete to the best of my knowledge. I understand that knowingly providing false information may result in denial of benefits and may subject me to civil or criminal penalties under applicable law.

Consent for Medical Treatment Related to TANF Services

I consent to all routine assessments and medically necessary treatments recommended by my health care providers that are reasonably related to the coordination of services under TANF. I have been informed of the nature, purpose, benefits, and potential risks of recommended treatments and have had the opportunity to ask questions.

I understand I may withdraw consent for treatment or this authorization at any time by providing written notice, except to the extent that action has already been taken in reliance on my consent.

Signature and Certification

By signing below, I certify that I am the patient or the patient's authorized representative, that I have read and understand this authorization, and that I consent to the release and use of my medical information as described above.

Witness (if required):

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