M E M O R A N D U M

IM-43  04/15/99  IM-6EBT FORM AND INSTRUCTIONS


SUBJECT:
AUTHORIZATION FOR REFERRALS FOR PROACTIVE PLANS (EBT)

FORMS MANUAL REVISION #13:  IM-6EBT FORM, AUTHORIZATION FOR RELEASE OF INFORMATION FORM AND INSTRUCTIONS
 
DISCUSSION:
County offices recently implemented proactive training plans targeted at elderly/disabled food stamp participants.  The plans focus on helping those participants who may need additional assistance using EBT.  Generally the plans stress training participants during the application process and, when necessary, referring participants to agencies or individuals who can provide follow-up assistance with using the EBT card.

The IM-6EBT is developed to assist staff with the referral process.  The participant signs this form authorizing the release of information regarding his/her situation to the agency/individual providing the assistance.  A copy of the form is sent to each agency/individual listed who can provide assistance.  The agency/individual records the action taken and returns the form once assistance is given to the participant.

The IM-6EBT form has been printed and an initial supply was sent to all county offices.  Additional supply can be requested using normal supply request procedures.
 
NECESSARY ACTION:
  • Review this memorandum with all appropriate staff.

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  • Use the IM-6EBT to obtain authorization for referrals made as a result of proactive plans for EBT training.

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  • File a copy of the IM-6EBT in the case record.

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  • File the IM-6EBT form and instructions in the IM Forms Manual.
REM
Distribution #3
Form not available on-line.  Refer to IM Forms Manual.
[ 1999 Memorandums ]