15
AUTHORITY TO RELEASE INFORMATION TO A DESIGNATED INDIVIDUAL
Complete this form if you authorize Eastern Shawnee Tribe of Oklahoma’s Health & Social Service
Program to release information to someone other than yourself. The individual you designate will
be able to acquire and receive information such as the status of your claim and benefit balance.
Please inform this individual to allow 30 days from your submission before calling the department
inquiring as to the status.
Choose One
I authorize Eastern Shawnee Tribe of Oklahoma’s Health & Social Service Program to release
information from my Health & Social Service records to the following individual
I withdraw my authorization to release information from my Health & Social Service records
to the following individual
YOUR DESIGNATED INDIVIDUAL’S INFORMATION
Full Name -- _______________________________________________________________________
Address -- ________________________________________________________________________
City, State, Zip -- ___________________________________________________________________
Telephone -- _________________________________________
Relationship to You -- __________________________________
I authorize the release of this information to the person named above for the following period of
time:
From: ______/______/__________ To: ______/______/__________
Tribal Members Name -- _____________________________________________________________
Birth Date -- ____________________________ Tribal ID # -- _____________________
If you are giving your authorization – I authorize the Eastern Shawnee Tribe of Oklahoma’s Health &
Social Service Program to release information from my Health & Social Service records to the
individual named above. I am aware that some information may not be release if it is subject to the
Privacy Act. I am aware that this form is to protect my confidentiality.
If you are withdrawing your authorization – I withdraw my authorization to release information from
my Health & Social Service records to the individual named above.
___________________________________ ___________________________________
Signature of Tribal Member Signature of Designated Individual
Date ______________________ Date _____________________
