Instructions for Form Dhs 1120 - Consent and Authorization to Disclose Confidential Information to All Household Members

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INSTRUCTIONS
DHS 1120 (06/15)
CONSENT AND AUTHORIZATION TO DISCLOSE CONFIDENTIAL INFORMATION TO ALL
HOUSEHOLD MEMBERS
PURPOSE:
The DHS 1120, Consent and Authorization to Disclose Confidential Information to All Household
Members form, authorizes Med-QUEST Division to disclose confidential information to all
household members within a case, age 18 years or older including any authorized representative.
GENERAL INSTRUCTIONS:
Upon receipt of this form, MQD Staff shall retain an electronic file for the case.
SPECIFIC INSTRUCTIONS:
1.
MQD Staff to input date form is to be returned by.
2.
MQD Staff to input contact information for an individual or household member to report any
change(s) in circumstance(s).
3.
Individual(s) 18 years or older to print full name, sign and date.
4.
MQD Staff to input mailing address form is to be delivered to.
5.
MQD Staff to input fax number form is to be sent to.
6.
MQD Staff to input unit address form is to be delivered to in person.
FILING/DISTRIBUTION INTRUCTIONS:
1.
Copy to be filed in case record
Page 1 of 1
INSTRUCTIONS
DHS 1120 (06/15)
CONSENT AND AUTHORIZATION TO DISCLOSE CONFIDENTIAL INFORMATION TO ALL
HOUSEHOLD MEMBERS
PURPOSE:
The DHS 1120, Consent and Authorization to Disclose Confidential Information to All Household
Members form, authorizes Med-QUEST Division to disclose confidential information to all
household members within a case, age 18 years or older including any authorized representative.
GENERAL INSTRUCTIONS:
Upon receipt of this form, MQD Staff shall retain an electronic file for the case.
SPECIFIC INSTRUCTIONS:
1.
MQD Staff to input date form is to be returned by.
2.
MQD Staff to input contact information for an individual or household member to report any
change(s) in circumstance(s).
3.
Individual(s) 18 years or older to print full name, sign and date.
4.
MQD Staff to input mailing address form is to be delivered to.
5.
MQD Staff to input fax number form is to be sent to.
6.
MQD Staff to input unit address form is to be delivered to in person.
FILING/DISTRIBUTION INTRUCTIONS:
1.
Copy to be filed in case record
Page 1 of 1

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