Effective Date: January 1, 2014

Previous Policy

The Department may not release enrollee information when it is to be used for a commercial or political reason. Income Match information may be released only to those parties who have access to it. (See section 111-3 #4 .)

1. Permission Granted by Applicants and Enrollees:

An applicant or enrollee can give written permission to release case record information.

Form 114AR

A. A valid permission form must include:

1) Individual’s name.

2) Individual’s Social Security number or PID number. There is an exception to this requirement if the individual has not provided a Social Security Number, and is not required to do so (i.e., someone who is not applying for benefits for themselves).

3) Individual’s date of birth.

4) Name of the person or organization to whom the individual is authorizing the release of information.

5) The purpose of releasing the information.

6) The date the release ends. It starts the date it is signed by the individual.

7) A statement as to how the individual or authorized representative can revoke the authorization.

8) A statement that explains that there is no obligation to sign the release and that CHIP eligibility will not be denied if it is not signed.

9) A statement indicating that the individual understands that once information is released, it may no longer be protected and may be re-disclosed.

10) The release must be signed and dated by whoever signed the application. If signed by someone other than the individual, describe their authority to sign.

Note: An applicant or recipient CANNOT authorize the release of Income Match Data from the case records. See 111-3 #4 below for additional information about Income Match Data.

B. There are two exceptions to obtaining permission from the enrollee before sharing information about him:

1) The reason for the request is listed in 111-3 #2, AND the request is NOT for Income Match information, AND the agency making the request has comparable rules for safeguarding its records.

2) It is an Emergency. If it is an emergency, you may release the information and then get the enrollee's permission, if the request is NOT for Income Match information, AND the agency making the request has comparable rules for safeguarding its records.

The CHIP Program Manager or his designee decides what an emergency is. Detail the nature of the emergency in the case notes.

2. Reasons You Can Release Information

With the exception of Income Match data, you may release information about CHIP enrollees when it will be used to administer medical assistance and Federal or State needs-based programs. This includes such reasons as:

A. To establish eligibility.

B. To provide related social services.

C. To assist in any investigation, prosecution, or criminal or civil proceeding connected with the administration of the CHIP program.

D. To confirm eligibility information for the current month for CHIP services.

Example: Information about a SSI recipient, spouse of an SSI recipient, or parents of an SSI recipient may be released to SSA. DO NOT require a written request from SSA. This is because SSA will use the information to administer the SSI program, which is needs‑based.

(See Section 111-3 #4 for the rules for release of Income Match data.)

3. To Whom You Can Release Information

The Department can release case record information to outside sources that must also safeguard their case record information on specific enrollees.

When an outside source requests safeguarded information, (other than the Social Security Administration, Dept. of Workforce Services or Office of Recovery Services), ask them how they are going to keep it confidential. Keep their written answer in the case record. Narrate what you did. If they cannot or will not tell you what their plan is to keep it confidential, you must not give them the information.

4. What Happens When Someone Requests Enrollee Information For A Reason Not Listed In 111-3 #2 ?

You must not release information to anyone for any reason not listed in 111-3 #2 unless the enrollee gives his permission.

If the case record gets subpoenaed by an outside source, call the CHIP Program Specialist, immediately.

The legal counsel for the Department will ask the court to disallow the information from our case records. He will cite the Federal Social Security Act and this manual material.

5. Taxpayers

There are no provisions for taxpayers to see any information from the enrollee's records .