(ML 2821 Rev. 11-02)
(Manual Renumbered effective 04/01/2004 ML2914)
(Appendix A)
While the recipient is considered the primary source of information for determining eligibility for assistance, collateral sources will sometimes need to be contacted for additional or verifying data.
Public records can be used for documentary evidence without the recipient's consent. With this exception, however, eligibility staff can take no steps to which the individual does not agree. Specific consent for outside contacts must be obtained after a clear explanation of whom will be contacted, what information is needed, why it is needed, and how it will be used.
SFN 1059, "Authorization for Release of Information," will assist the county office in obtaining information from outside individuals, agencies, and institutions. When properly completed and signed, the form gives the recipient's permission to seek the data needed. SFN 1059 must be used to obtain personal health information and may be used to obtain financial information. In addition, the SFN 405, "Application for Assistance" contains an authorization to release information which may be used in lieu of SFN 1059, "Authorization for Release of Information," to obtain financial information. However, if the release of information from the application form is used, an accompanying letter must contain information detailing the information that is being requested.
Completion of SFN 1059 is largely self-explanatory. After explaining the need for additional or verifying data from collateral sources, the county office shall list the name(s) of the individual(s), agency(ies), and/or institution(s) to be contacted for the information needed to establish eligibility. The individual’s consent for the release of information will normally remain in effect for the period necessary to accomplish the purpose for which the consent was requested. The form must be signed by the recipient and, if appropriate, by his/her spouse. Names of additional individuals, agencies, or institutions may not be added to the form after it has been signed.
The names of all collateral sources that need to be contacted can often be listed on a single SFN 1059. Eligibility staff, however, should be sensitive to situations in which this could cause unnecessary embarrassment to the individual. If including an individual, agency, or institution on the same consent form with others that need to be contacted could cause embarrassment, that particular collateral source should be isolated by being listed on a separate SFN 1059.
SFN 1059 may also be used if a recipient wishes to have file information transmitted to another agency or individual.
Distribution of SFN 1059 shall be as described on the form.
A copy of this form is found in printed copy or on the Discover ND web page – E-Forms SFN 1059. You can type on the form and print it.