Forms

The table below describes the forms used by HCA and DSHS for the following purposes:

Designating an AREP

Authorizing consent to share information

Releasing agency records

Type of form and questions Authorized representative Consent to use and share confidential information Authorization to release agency records HCA forms 18-001 (14-430 for pregnant teens) * See note 80-020 DSHS forms 14-532 or 18-005 ** 14-012 17-063 When to use? To authorize the agency to exchange with the AREP only the information needed to determine eligibility for Apple Health programs. HIPAA restrictions prevent us from discussing the person's individual health information with an AREP unless a current signed DSHS 14-012 consent form is in the record. To give consent for the agency to exchange more information with health care providers or other agencies (as identified on the form) than the basic eligibility information that can be shared with an AREP. DSHS Form 14-012 is HIPAA-compliant. To authorize the agency to release agency records and other information (as identified on the form) to the person or organization (as identified on the form). DSHS Form 17-063 and HCA Form 80-020 are HIPAA-compliant. Who processes the request? If the individual designates an AREP in Healthplanfinder (which the individual can do anytime), Healthplanfinder accepts the request when submitted. Outside of Healthplanfinder, the AREP designation is received and entered into ACES or Healthplanfinder as follows: HBE staff process HCA Form 18-001 (Medicaid paper application). HCA medical assistance specialist (MAS) staff process HCA Form 18-001 and DSHS Form 14-532 sent to HCA. DSHS public benefit specialist (PBS) staff process all HCA Form 18-005 (Classic Medicaid paper application) and DSHS Form 14-532 sent to DSHS. DSHS receives DSHS Form 14-012 and uploads it into the Electronic Case Record (ECR). Only the Public Disclosure Unit at HCA or DSHS can approve or deny requests to release agency records, whether on HCA Form 80-020 or DSHS Form 17-063 or by other correspondence. How long is the designation effective? An AREP designation on HCA Form 18-001 or HCA Form 18-005 or DSHS Form14-532 is effective until applicant/recipient revokes or AREP notifies they are no longer the AREP An AREP designation is effective until revoked by the client or authorized representative unless otherwise designated by the applicant/recipient and automatically terminates when a person dies. The consent on DSHS Form 14-012 is effective for the period of time specified on the form. The authorization to release records on HCA Form 80-020 or DSHS Form 17-063 is effective for the period of time specified on the form.

* The consent to Use and Share Confidential information form is not required for HCA to obtain information from a provider.

**To designate an authorized representative complete DSHS forms 14-532 or designate your authorized representative on the completed Washington Apple Health Application for Aged, Blind, Disabled/Long-Term Services and Supports ( 18-005 , page 16).

Carefully review consent forms

Every signed consent form is unique, so it is critical that the authorized information, designated parties, and effective dates be carefully reviewed before releasing information.