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ACCESS Partner View System Release

Customer’s Name: ACCESS Case#:

I, , understand that by my signature I am authorizing the Department of Children and Families (DCF) to release limited case information to Treasure Coast Food Bank in their role as a DCF Community Partner and shall be used solely to fulfill their obligation in assisting me with the application filed with DCF on . Information to be released is limited to

Verifying my eligibility information (approved, denied, enrolled or pending)
Reason for closure or denial
Assisting me with information on scheduled interview dates and time
Assisting me with understanding what information is needed to complete my case and the dates the information is due
Assisting me with printing a temporary Medicaid card for eligible members in my household
Assisting me with opening an account through My ACCESS Account

No additional information shall be provided to the Community Partner without my specific written consent. This authorization expires no more than ninety (90) days from the date signed.

Dated: December 8, 2024

Community Partner Staff:

Date of Birth:

Printed Name:

Signed:

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Timestamp

Audit

July 30, 2024 2:52 pm EST

ACCESS Partner View System Release Uploaded by Daniel Torres - donotreply@tcfoodbank.org IP 172.82.125.4

July 31, 2024 2:34 pm EST

Ruby Aguirre - raguirre@wholechildmartin.com added by Daniel Torres - donotreply@tcfoodbank.org as a CC'd Recipient Ip: 172.82.125.4

July 31, 2024 2:49 pm EST

Ruby Aguirre - raguirre@wholechildmartin.com added by Daniel Torres - donotreply@tcfoodbank.org as a CC'd Recipient Ip: 172.82.125.4

July 31, 2024 4:34 pm EST

Ruby Aguirre - raguirre@wholechildmartin.com added by Daniel Torres - donotreply@tcfoodbank.org as a CC'd Recipient Ip: 172.82.125.4

August 7, 2024 10:49 am EST

Ruby Aguirre - raguirre@wholechildmartin.com added by Daniel Torres - donotreply@tcfoodbank.org as a CC'd Recipient Ip: 172.82.125.4