Get Dhs 1123 Instructions 2013-2025

The DHS 1123 Instructions provide a crucial framework for authorizing the disclosure of confidential information by the Med-QUEST Division. This guide will help users navigate the steps to successfully complete the form online.

Follow the steps to fill out the DHS 1123 form online effectively.

1. Press the ‘Get Form’ button to access the DHS 1123 form and open it in your preferred online editor.
2. Enter the full name of the individual granting authorization for disclosure in the first field.
3. If the authorizing individual is a legal representative, specify the type of legal appointment, such as lawyer, court order, legal guardian, or legal parent. Be sure to attach a copy of the legal authorization to the DHS 1123 form.
4. Check the appropriate boxes for the information being requested. For any additional details, especially under ‘Other’, provide specific information and service dates.
5. If applicable, enter the name of the applicant or beneficiary if it differs from the person listed in step 1.
6. Input the Social Security Number and/or Date of Birth of the applicant or beneficiary.
7. List the name of the person or agency that is authorized to receive the information.
8. Indicate the relationship of the person or agency to the applicant or beneficiary, if any.
9. Provide the mailing address where the authorized person or agency can receive the information.
10. Enter the phone number for the individual or agency that will receive the information.
11. Describe how the authorized person or agency will use the information. Note that applicants or beneficiaries do not need to complete this section for information released to themselves.
12. Enter the date or event that will terminate the authorization. If this section is left blank, the authorization will automatically expire one calendar year from the date of authorization.
13. Finally, the person authorizing the disclosure must sign and date the form and provide their mailing address.

Complete your DHS 1123 form online today for an efficient and streamlined process.