"Permission to Share Information Form" - Massachusetts

The Massachusetts Department of Transitional Assistance has released this version of the "Permission to Share Information Form" on March 1, 2018.

This form may be used by all Massachusetts residents: download the printable PDF by clicking the link below and use it according to the applicable legal guidelines.

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Download "Permission to Share Information Form" - Massachusetts

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Department of Transitional Assistance
Permission to Share Information Form
All organizations must submit the client signed form by:
Email to
DTA.ProviderPortal@Massmail.State.MA.US
or
Fax to 617-889-7849
Section 1: DTA Client or Applicant
_________________________________________________________
Client/Applicant Name
______________________________________
_______________________
DTA Agency ID or Last Four Digits of SSN
Date of Birth
Section 2: Information to be Shared
I allow DTA to give or get information about my TAFDC, EAEDC and/or SNAP case with the
organization named in Section 3.
Section 3: Organization to Receive the Information
_______________________________________________
_________________________
Name of Organization
Phone Number
________________________________________________________
________________________________
Address of Organization
______________________________
DTA Connect Organization ID
Section 4: Right to Change Your Mind
You may change your mind and stop the release of this information. To stop it, you must:
 call 1-877-382-2363 during regular business hours and speak to a DTA Representative; or
 send a written request to: DTA Document Processing Center, P.O. Box 4406, Taunton, MA 02780
or fax to (617) 887-8765
Section 5: Signature
I understand that when I sign below, I am giving permission to DTA to give or get information on my case.
_______________________________________________
_____________________
Client/Applicant Signature
Date
This form is valid for one year from the date of the applicant/client signature, unless revoked (see Section 4).
This institution is an equal opportunity provider.
Esta institución es un proveedor que ofrece igualdad de oportunidades.
Department of Transitional Assistance
DTA Connect Permission to Share Information (PSI) Form
Rev 3/2018
Department of Transitional Assistance
Permission to Share Information Form
All organizations must submit the client signed form by:
Email to
DTA.ProviderPortal@Massmail.State.MA.US
or
Fax to 617-889-7849
Section 1: DTA Client or Applicant
_________________________________________________________
Client/Applicant Name
______________________________________
_______________________
DTA Agency ID or Last Four Digits of SSN
Date of Birth
Section 2: Information to be Shared
I allow DTA to give or get information about my TAFDC, EAEDC and/or SNAP case with the
organization named in Section 3.
Section 3: Organization to Receive the Information
_______________________________________________
_________________________
Name of Organization
Phone Number
________________________________________________________
________________________________
Address of Organization
______________________________
DTA Connect Organization ID
Section 4: Right to Change Your Mind
You may change your mind and stop the release of this information. To stop it, you must:
 call 1-877-382-2363 during regular business hours and speak to a DTA Representative; or
 send a written request to: DTA Document Processing Center, P.O. Box 4406, Taunton, MA 02780
or fax to (617) 887-8765
Section 5: Signature
I understand that when I sign below, I am giving permission to DTA to give or get information on my case.
_______________________________________________
_____________________
Client/Applicant Signature
Date
This form is valid for one year from the date of the applicant/client signature, unless revoked (see Section 4).
This institution is an equal opportunity provider.
Esta institución es un proveedor que ofrece igualdad de oportunidades.
Department of Transitional Assistance
DTA Connect Permission to Share Information (PSI) Form
Rev 3/2018
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