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Get DHS 1123 Instructions 2013-2022

HE MEDQUEST DIVISION (MQD)* form authorizes Med-QUEST Division to disclose confidential information to an applicant, beneficiary, legal representative, or third party. GENERAL INFORMATION: Upon receipt of this form, MQD staff shall send the original copy to MQD/Administration and retain a copy for the case or electronic file. SPECIFIC INSTRUCTIONS: (1) Enter the full name of the person who is authorizing the disclosure. (2) (3) (4) (5) (6) (7) (8) (9) If a person is a legal representative, .

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