Get State Form 54584

Filling out the State Form 54584 is an essential step to authorize the disclosure of your personal and health information. This guide aims to assist you in navigating the online process with clear, step-by-step instructions tailored to your needs.

Follow the steps to complete the form accurately.

1. Click the ‘Get Form’ button to access the form and open it in your browser.
2. Enter your name and identification information, including your address, city, state, ZIP code, telephone number, date of birth, email address, and the last four digits of your Social Security number.
3. In the section regarding personal information disclosure, clearly describe the type of information you are allowing to be shared, such as your contact details, benefits status, medical condition, or other relevant data.
4. State the purpose of the requested disclosure by describing how the information can be used, for instance, assistance with accessing benefits or for legal support.
5. Specify the names of individuals or organizations to whom your personal information may be disclosed, along with their contact information.
6. Select the DDRS program areas you are authorizing to disclose your information, such as Bureau of Child Development Services, Bureau of Developmental Disabilities Services, or Bureau of Quality Improvement Services.
7. Indicate the expiration date for this authorization, choosing between automatic expiration in sixty calendar days, a specific date, or a specific event.
8. Review your understanding of your right to revoke this authorization at any time and acknowledge that partial disclosures may have occurred prior to revocation.
9. Sign and date the form to confirm your authorization.
10. If applicable, complete the section for a personal representative, providing their name, contact information, and relationship to the individual.
11. After completing the form, you can save changes, download, print, or share it as needed.

Complete your documents easily online to maintain control over your personal and health information.