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State of Maryland Medical Assistance Manual Revised April 2014
Attachment A
Consent to Release Information Form I understand that as an Applicant /Recipient of Medical Assistance. I authorize the release to the Department of Health and Mental Hygiene (The Department) and/or its delegate agencies of all data, records, and information by insurance companies, non-profit health services plans, providers of medical care, employers, agencies or organization necessary for The Department’s pursuit of third party reimbursement or verification of my statements provided in this application. I understand that this is signed statement serves as written authorization for any of the above person, agencies, or organizations to release the information requested. The social security number of every Medical Assistance applicant/recipient will be used to obtain and verify information concerning his/her unearned income, cash benefits, wages and resources. I give my consent for The Department and/ or its delegate agencies to compare the information I have given with the records of Federal, State, local and private agencies or businesses.
Signature of Applicant
Date