Release of Medical Information

I am requesting that the attached Medical Verification form be completed.

In order to receive temporary cash assistance and prepare individuals and families for self-sufficiency, individuals receiving cash assistance are required to participate in countable work activities. Additionally, Florida limits such families to receive cash assistance for a total of 48 months. Some participants may receive a medical deferral as a result of an injury, a temporary medical condition, or other good cause reason. However, if a participant is in deferred status, he/she continues to be subject to the cash assistance time limits.

I understand that I have given the physician permission to complete the medical verification form.

• I understand that the information will state my current diagnosis and possible limitations to engage in countable work activities. By completing the medical form, I am requesting that my physician provide the information to the Welfare Transition Program (WTP) provider.
• The information on the form will be used to develop a personalized self-sufficiency plan that takes my limitations, medical needs and treatment into consideration. The completed form may also be used when considering an extension to my cash assistance time limits.

Rights

• I have the right to refuse to sign the Release of Medical Information Form.
• The authorization of the Medical Verification Form may not condition medical treatment, payment, or enrollment.
• I understand that I have the right to revoke the authorization of this form. To revoke the authorization, I must submit a request in writing to both the physician and the WTP provider
• Once the form is completed, the form will be included in my case file, but the information may not be used to determine limitations or medical inability after six months from the physician’s signature date.
• I have the right to privacy. The medical verification form and information that is given in the form is confidential health information. The WTP provider is the sole recipient of the information. The information may be disclosed only in the course of official business and the verification of continued eligibility/compliance.

Responsibilities

• I have agreed to have the form completed and return the completed form to my career consultant by

• If I refuse to sign the form or fail to supply the required information by the above date, I must participate in the Welfare Transition Program’s (WTP) countable activities for the minimum required hours unless another good cause reason is documented.
• I must complete the activities as indicated on my self-sufficiency plan. Refusal to sign the form and failure to participate in countable activities may result in the reduction or cancellation of my cash assistance and food stamp benefits.
• If I refuse to participate in the program and fail to complete the agreed upon activities listed in my self- sufficiency plan, my benefits may be reduced or cancelled.
• If the form is revoked, I am still responsible for completing the activities I agreed to complete on my self-sufficiency plan.

 

I have reviewed my rights and responsibilities with my career consultant.

Expiration of Request is 60 days from signature date.

Privacy Statement

I understand that I am required by law to provide my social security number(s) or proof that I have applied for a social security number if I do not currently have one to receive TANF funded benefits/services. This is mandatory under the Social Security Act (42 U.S.C. 1137). If I do not have a social security number and have not applied for a social security number, I can request help with filing an application. The social security number is used to administer the program, including determining eligibility, attributing the receipt of services, correspondence and participation to my case, as well as for reporting purposes.

An equal opportunity/employer program. Auxiliary aids and services are available upon request to individuals with disabilities. All voice telephone numbers on this document may be reached by persons using TTY/TDD equipment via the Florida Relay Service at 711.