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Effective Date: 
1/2020

Documents

 

Instructions

Updated: 1/2020

 

Purpose

Form 3076 is used as the household member’s authorization to release information that will help determine the household’s County Indigent Health Care Program (CIHCP) eligibility.

 

When to Prepare

Complete an original and one copy of Form 3076. Issue the original to the person or agency that will provide the requested information. File the copy in the case record.

 

Form Retention

Maintain the copy of Form 3076 in the case record at least until the end of the third complete state fiscal year following the date on which Form 3076 is submitted.

 

Detailed Instructions

Case Record Name and Case Record No. – Enter the case record name and case record number.

Specific Request – Check this box if the client wants to limit the release of information to specific items or a specific time period.

Information Requested – Enter the type of information requested, such as type and amount of benefits, amount of income or degree of disability.

Period Covered (Dates) – Enter the period covered for specific information to be released, such as “for September 2019” and “pertinent to the September 2019 certification.”

General Request – Check this box if there are no restrictions on the type of information to be released. The applicant or recipient for whom the information is being requested must sign and date Form 3076.  The spouse and one witness signs and dates Form 3076, if applicable.