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Aa Roi

Elevate PFS has been appointed as a representative by Arina Alic to assist with her Medicaid application. The document authorizes Elevate PFS to obtain any necessary information from public agencies, private businesses, health providers, and the Social Security Administration to facilitate the application process. Arina Alic also authorizes Elevate PFS and its affiliates to contact her by phone, text, email, or other digital means regarding her medical care, services, and accounts. This authorization is effective for one year from the date of her application approval, denial, or closure.

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Arina Alic
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12 views1 page

Aa Roi

Elevate PFS has been appointed as a representative by Arina Alic to assist with her Medicaid application. The document authorizes Elevate PFS to obtain any necessary information from public agencies, private businesses, health providers, and the Social Security Administration to facilitate the application process. Arina Alic also authorizes Elevate PFS and its affiliates to contact her by phone, text, email, or other digital means regarding her medical care, services, and accounts. This authorization is effective for one year from the date of her application approval, denial, or closure.

Uploaded by

Arina Alic
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
Download as pdf or txt
Download as pdf or txt
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ARINA ALIC

_______________________________ ___________________ ___________________________


Name Date of Birth Social Security Number

Release of Information
Medical Assistance Purposes Only

ARINA ALIC
I, ___________________________________________ appoint Elevate PFS (EPFS) as my representative to
assist me with my Medicaid or other medical assistance application, including requesting and representing me
at an administrative fair hearing, or on appeal. To facilitate the application process, I state as follows:

1. I request that any public medical assistance agency provide all information about my application to EPFS, including
correspondence, information requests, interview dates, Spenddown notices, and notification of eligibility status.
2. I authorize EPFS, in states where online Medicaid applications are accepted, to create a username and password and
submit my medical assistance application online to the State agency for determination.
3. I authorize the Social Security Administration and any other private or public agency or business, to disclose to EPFS
any and all information requested by EPFS that may be necessary for the application process, including without
limitation employment records, bank statements, financial records, child care costs, insurance information, identity
documents (including social security number and photograph), and housing and utility information.
4. I authorize any of my health care providers to disclose any and all of my medical and billing records (including records
pertaining to AIDS/HIV, alcohol/drug abuse treatment, or behavioral/mental health services) to EPFS.
5. I authorize EPFS and its affiliates, employees and agents:
(1) to call or text me at any telephone number I have provided to EPFS or my health care provider, including
any wireless/cell phone number
(2) to leave answering machine or voice mail messages for me
(3) to send emails to any email address I have provided to EPFS or my health care provider
(4) to use pre-recorded/artificial voice or text messages and/or automated dialing devices (autodialers) in
connection with any communications to me related to my medical care, services and accounts.
6. I authorize EPFS to submit information obtained pursuant to this release to the appropriate medical assistance agency.

This authorization, or any portion of it, may be revoked by sending written notification to
[email protected]. Revocation will not affect any action taken in reliance on this authorization before the
revocation is received. This authorization shall be effective until one year after my medical assistance application is
finally approved, denied or closed. I have the right to receive a copy of this form.

________________________________________________________________
July 19, 2023
_______________________
Signature of Patient-Representative Date

SELF
____________________________________________ Relationship to Patient
Refusing to sign this authorization will not impact my eligibility for benefits or services. .

Copies or faxes of this release are acceptable. UPDATED 03252022

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