Ona application for families dvr 199 e


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Ona application for families dvr 199 e

  1. 1. Send Records to: Department of Workforce Development State of Wisconsin Division of Vocational RehabilitationOperation Noahs Ark CorporationFEIN: 91-2151249 Authorization for Release of1700 E. Thompson Blvd. Suite F-693 Confidential InformationVentura, CA 93001 1-888-306-9679Person or Organization Authorized to Release Records: Name and Address of Subject of the Record: Deseased Date of Birth:        Cornors Office, Public Administrator Office, Federal, State, County CourtHouse, Funeral Home, Cemetary, IRIS Number:        Next of kin family memberThis form is voluntary and you are not required to give us personal data but DVR may need these records before we can provideservices to you. Records include verbal and written information. DVR routinely shares data with the Social Security andWorker’s Compensation program. DVR also has agreements to share data as permitted by state and federal law. If recordsinvolve diagnosis or treatment of mental illness, developmental disabilities, alcohol abuse or drug abuse, you have the right toinspect and receive a copy of those records except for medication and somatic treatment. This right may be denied by the facilitytreatment director or designee in some circumstances. Reasonable fees for copies are allowed. If you need help to complete thisform, ask the person who gave you the form or call DVR at 1-800-442-3477 (Voice) or 1-888-877-5939 (TTY). Please check the appropriate box(es) below to indicate which records should be released. Medical records including records of general health and of diagnosis or treatment of alcohol or drug abuse treatment, mental illness, or other mental impairment and HIV/AIDS treatment. Include the physicians signature and dates for diagnosis, treatment, and prognosis. Cause of Death Educational records (including transcripts and school psychologist’s report documenting impairment). if any Financial information (including student financial aid packages). 2011-2012 Tax W-2 Forms of the deseased and applicant Psychological testing (including vocational evaluations). For Federal and State Statistics Social History. Criminal Records for fraud protection against entity and government agencies Employment Records. Proof of indigent and low-income status or presidential decleared disaster Other records listed here. Attach additional sheets if needed. Individual must sign and date attachments. Death Certifercate and coroners reports copies of state Identification or Drivers License of the deseased and applicant (next of kin) Birth and Death Certifercates Copy of the Will and or deceaseds last wishes if anyPurpose For This Request And Limits Of This Authorization: To receive information from cononers office, funeral and cemetary directors and to verify with local, state and federal government officals in regards to the death records of the deseased and also information on the applicant who has requested assistance from the nonprofit entity Operation Noahs Ark CorporationIf you have questions, call the sender. My signature is authorization for release of the records specified above. I understand that Imay revoke this authorization, in writing, at any time except to the extent that information was released as a result of thisauthorization. Unless revoked, this authorization remains in effect until the time stated below. No further release of these recordsis authorized without my informed written consent except as provided by 34 CFR 361.38 and s. DWD 68, Wi. Adm. Code. If noexpiration date is specified, the authorization expires one year after the date it was signed.A photocopy or facsimile of this Release Of Information Request is as valid as an original.I understand I have the right to receive a copy of this release of information, the right to refuse to sign this release of information,the right to withdraw this release of information at any time, and the right to inspect a copy of the information obtained by thisrelease of information.This authorization expires on this specific date 07/24/2013This authorization expires when this specific action occurs 1 year from 07/24/2012Consumer Signature (or Signature of Guardian if under 18 or court Date Signedappointed)
  2. 2. If you are not the subject of the record, what is your relationship to the Next of Kin on Will if there is subject no Will the Probate is through the County Clerks office and or Public Administrators office of the county deseased resided living in.DVR-199-E (R. 06/2009)