Page 53

State of Maryland Medical Assistance Manual Revised April 2014

CONSENT FOR RELEASE OF INFORMATION

REGARDING AN APPLICATION OR REDETERMINATION FOR MEDICAL ASSISTANCE LONG –TERM CARE BENEFITS

This form authorizes the Local Department of Social Services to release information to the Long-Term Care facility.

I,

, authorize the

Department of Social Services to release all necessary information from or about my application or redetermination for Medical Assistance benefits to the following long-term care facility (e.g., nursing home) where I live.

Name of facility Address

This information may be released to the following person (s):

Name (please print)

Position

Telephone Number

Name (please print)

Position

Telephone Number

Name of Applicant/Recipient (please print)

CID #

___________________________________ Signature of Applicant/Recipient or authorized representative Applicant/Recipient Social Security Number

Date

This form is valid for 12 months from date of signature.

DES 2005 Revised 11/03