PURPOSE: To obtain authorization from the participant for release of information regarding the EU’s situation. This form is used to obtain assistance with the EBT process through outside agencies working with FSD.
Number of Copies and Distribution: One copy for each referral which requires an authorization and one copy for the case file is needed.
Instructions for Completion: This form may be handwritten. The top of the form corresponds to the county letterhead.
To: The name and address of the agency/individual to which the participant is referred is entered in these lines.
RE: Enter the case name and case number of the participant who is giving authorization for a referral.
Referral: The worker and the agency/individual to whom the referral is made complete this section.
Agency/Individual name: Enter the name of the agency or individual that is working with FSD to provide EBT assistance to participants. There are three spaces for the agency/individual name(s).
Referral Date: Enter the date the referral is made.
Action Taken: The agency to which the participant is referred completes this section by recording the action taken to assist the participant with EBT. For example, took the participant shopping, assisted participant with phone call to obtain new PIN, etc.
Participant Signature: Signature of the person giving authorization is entered.
Date: The date the participant signs the form is entered.
Signature of FSD staff: Signature of the staff member making the referral is entered.
Date: The date the staff member signs the form is entered.