Indiana
Authorization for disclosure of personal and health information
No One Left Outside provides source-based information. The issuing agency or plan decides eligibility, acceptance and availability.
Source / last checked DFR: Forms - 2026-11-02
- Form number
- 54621
Authorization for disclosure of personal and health information - Reviewed 2026-11-02
- What it is for
- Authorization for disclosure of personal and health information
DFR: Forms - Reviewed 2026-11-02
- Issuing agency
- Indiana Family and Social Services Administration (FSSA); this form appears in the DFR forms catalog.
DFR: Forms - Reviewed 2026-11-02
- Program
- Which DFR program areas are you authorizing to disclose your personal information? Medicaid Eligibility Supplemental Nutrition Assistance Program (SNAP)/Food Stamps Child Care Assistance Temporary Assistance for Needy Families (TANF) Other
Authorization for disclosure of personal and health information - Reviewed 2026-11-02
- Jurisdiction
- Indiana
DFR: Forms - Reviewed 2026-11-02
- Category
- PERSONAL AND HEALTH INFORMATION
Authorization for disclosure of personal and health information - Reviewed 2026-11-02
- Form type
- form
DFR: Forms - Reviewed 2026-11-02
- Who fills it out
- Purpose For you to authorize the disclosure of your personal information, which may include health information, to persons or organi - zations outside of the Division of Family Resources (DFR). Your privacy is protected by state and federal privacy laws. As such, we need your explicit permission to make the requested disclosure. Please complete each section of this form.
Authorization for disclosure of personal and health information - Reviewed 2026-11-02
- How to submit
- General DFR forms-catalog route: fax 888-436-9199, or deliver or mail to your local county office. Follow document-specific instructions where supplied.
DFR: Forms - Reviewed 2026-11-02
- Documents to include
- Not listed yet. Call to confirm.
- Languages
- English
Authorization for disclosure of personal and health information - Reviewed 2026-11-02
- Official page
- https://www.in.gov/fssa/dfr/forms-documents-and-tools/forms
DFR: Forms - Reviewed 2026-11-02
- Direct form link
- https://forms.in.gov/Download.aspx?id=9491
DFR: Forms - Reviewed 2026-11-02
- Revision date
- 2-11
Authorization for disclosure of personal and health information - Reviewed 2026-11-02
- Signature
- Signature Having had full opportunity to read and consider the contents of this authorization, including my rights and the risks of fur - ther disclosure as described above, I am authorizing DFR to disclose my personal information, including health information, to the persons or organizations I have identified above. I understand DFR will disclose only that information which is neces - sary to accomplish the stated purpose of the disclosure. The information disclosed will be limited to the minimum necessary. I also understand that I am under no obligation to sign this authorization. I also understand that the services and benefits provided to me by or through DFR will not be affected whether or not I sign this form. Signature Date If this authorization is signed by an individual’s personal representative on behalf of the individual, please complete the following:
Authorization for disclosure of personal and health information - Reviewed 2026-11-02
- Accessibility
- Not listed yet. Call to confirm.
- What the form says
Further Disclosure Once we disclose your personal information, including health information, to the above persons/organizations, the information may no longer be protected under state or federal privacy laws. We cannot control what these persons/organizations do with your information.
Authorization for disclosure of personal and health information - Reviewed 2026-11-02
Check the form number and revision before using it. Read the agency's privacy and consent terms before sharing personal information.