Get Authorization For Release Of Case Status Information - State Of Indiana - State In

Filling out the Authorization For Release of Case Status Information form is an important process for obtaining the necessary information regarding your case status in Indiana. This guide will provide you with the step-by-step instructions needed to complete the form accurately and effectively online.

Follow the steps to fill out the form correctly

1. Click the ‘Get Form’ button to access the Authorization For Release Of Case Status Information form and open it in your chosen editor.
2. In Section A, provide your full name as the applicant or recipient, along with your date of birth. Ensure to enter the last four digits of your Social Security number, your complete address including city, state, and zip code, and your contact phone number.
3. Next, in Section A, enter your Public Assistance Case Number, which should be provided on any correspondence you have received regarding your assistance.
4. Moving to Section B, indicate the agency or organization that you authorize to receive, use, or disclose your case status information. Include their complete address, city, state, zip code, and phone number. Remember, only one organization can be specified on this authorization.
5. In Section C, read and understand the information about your right to revoke the authorization. This section informs you that access will remain until revoked and describes how to proceed with revocation.
6. In Section D, confirm your understanding of the authorization, including the voluntary nature of signing and the potential implications of releasing your information. Ensure you or your legal representative signs this section.
7. Finally, in Section E, sign and date the form. If you are signing with an ‘X’, ensure a witness signs beside you. An agency representative may also need to confirm the authorization by signing.
8. Once you have completed the form, save your changes, and proceed to mail or fax it to the FSSA Document Center at the address provided. Make sure to retain a copy for your records.

Complete your documents online today to streamline your case status information requests.