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AUTHORIZATION TO RELEASE INFORMATION FORM
THIS FORM MUST BE COMPLETED AND ON FILE BEFORE ANY SERVICES WILL BE CONSIDERED
Please list all individuals living in the household ---- Date ____________________
Family Member Relationship Social Security # Sex Date of Birth Roll #
I hereby give permission for the Eastern Shawnee Tribe, teacher or school, physician, dentist,
optometrist, energy company, hospital or any other organization, healthcare provider or persons
providing service to me and maintaining information about me to release information to the Health
and Social Service Department. This information shall include verification that the patient was seen
on a certain day, whether a healthcare insurance company or other party was billed for the service
rendered and documentation of any payments received, the dates that said patient received medical
treatment or otherwise from the healthcare provider and an original bill and/or original itemized
statement for services rendered to the patient. The Health and Social Service Department requests
such information for the purpose of determining eligibility for social services and legitimacy of claims.
I understand that I have the right to revoke this authorization at any time by written notice to the
Eastern Shawnee Health and Social Service Department at 10100 S. Bluejacket Rd., Ste. 1, Wyandotte
OK 74370. I am aware that my revocation of this authorization will not be effective to the extent the
persons and/or organizations identified above have already acted in reliance upon this authorization.
I understand that my revocation of this authorization may prevent or delay me from receiving services
from the Eastern Shawnee Health and Social Service Department.
I have read, understand and agree to comply with the requirements of eligibility for the Health and
Social Service Department of the Eastern Shawnee Tribe of Oklahoma. I also understand that the
guidelines are set forth for the fair and equal treatment of each enrolled tribal member of the Eastern
Shawnee Tribe of Oklahoma. If any of the above information changes, it is my responsibility to notify
the Eastern Shawnee Health and Social Service Department in writing.
Head of Household ______________________________________________
Address ______________________________________________
______________________________________________
City/State/Zip ______________________________________________
Daytime Phone ______________________________________________
SUBMITTING FRAUDULENT CLAIMS IS A FEDERAL CRIME UNDER 18 CFR PART 1 CHAPTER 53
§1163. PRIVACY AND CONFIDENTIALITY IS PROTECTED UNDER 42 CFR.
