I,

hereby authorize Union County Human Services to disclose the information listed below to Third Party Transportation Services for the purpose of determining eligibility for cash assistance, medical assistance and/or food stamp benefits; or for the following reason(s): to verify eligibility for transportation services.

Information to be released: Current status of Medicaid benefits, eligibility begin and end dates, and any other non-PHI information necessary to determine eligibility for transport services.

By signing this digital form, I understand that:

This authorization shall expire [ONE YEAR FROM SIGNATURE] or until revoked by me in writing, whichever comes first.

I have the right to revoke or cancel this authorization at any time by providing notice in writing to the following address:

Union County Human Services

PO Box 389

Marysville, OH 43040

The revoking or cancelling of this authorization does not affect the use or disclosure of information that occurred prior to the date that authorization was canceled.

Any information used or disclosed per this specific authorization may be re-disclosed by the person or entity receiving the information. In such a situation, it may no longer be protected by federal or state law.

This authorization is NOT for the release or use of protected health information (PHI) - please use the appropriate medical release authorization form.

I am aware of my responsibilities to report completely and fully all facts that bear upon my eligibility for all cash assistance, medical assistance, and/or food stamp benefits. I realize if the requested information reveals I have improperly reported my situation, the information may be given to the prosecuting attorney for possible civil action or criminal prosecution.

Completion of this form is voluntary, but necessary to determine eligibility for cash assistance, medical assistance, and/or food stamp benefits.