BFA Form 11 "Authorization to Release Information" - New Hampshire

What Is BFA Form 11?

This is a legal form that was released by the New Hampshire Department of Health and Human Services - Bureau of Family Assistance - a government authority operating within New Hampshire. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2019;
  • The latest edition provided by the New Hampshire Department of Health and Human Services - Bureau of Family Assistance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of BFA Form 11 by clicking the link below or browse more documents and templates provided by the New Hampshire Department of Health and Human Services - Bureau of Family Assistance.

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Download BFA Form 11 "Authorization to Release Information" - New Hampshire

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NH Department of Health & Human Services (DHHS)
BFA Form 11
Bureau of Family Assistance (BFA)
10/19
Authorization to Release Information
Printed Name of Person to Whom the Release of Information Pertains
Case #, RID #, or MID #, if known
I hereby authorize and request:
Name and Address of
Individual or Agency
Providing the Information:
to provide the following information:
to:
Name and Address of
Individual or Agency
Receiving the Information:
I grant my permission for the reproduction of the above information to be given to the individual or agency
named. Release of confidential information is subject to State and Federal laws. By signing this release, I
acknowledge my permission to release the specified information to the individual/agency I have named.
This authorization expires 12-months from the date this form is signed.
Information released cannot be re-released by the receiving individual/agency without additional
authorization.
(Signature)
(Date)
(Printed Name)
If the signature above is not that of the person to whom the information pertains, the relationship of the signer
to that person must be indicated. In addition, the signature must be witnessed.
(Relationship)
(Witness)
(Date)
BFA SR 19-29
(3YC)
NH Department of Health & Human Services (DHHS)
BFA Form 11
Bureau of Family Assistance (BFA)
10/19
Authorization to Release Information
Printed Name of Person to Whom the Release of Information Pertains
Case #, RID #, or MID #, if known
I hereby authorize and request:
Name and Address of
Individual or Agency
Providing the Information:
to provide the following information:
to:
Name and Address of
Individual or Agency
Receiving the Information:
I grant my permission for the reproduction of the above information to be given to the individual or agency
named. Release of confidential information is subject to State and Federal laws. By signing this release, I
acknowledge my permission to release the specified information to the individual/agency I have named.
This authorization expires 12-months from the date this form is signed.
Information released cannot be re-released by the receiving individual/agency without additional
authorization.
(Signature)
(Date)
(Printed Name)
If the signature above is not that of the person to whom the information pertains, the relationship of the signer
to that person must be indicated. In addition, the signature must be witnessed.
(Relationship)
(Witness)
(Date)
BFA SR 19-29
(3YC)
NH Department of Health & Human Services (DHHS)
BFA Form 11
Bureau of Family Assistance (BFA)
10/19
Nondiscrimination Statement
This institution is prohibited from discriminating on the basis of race, color, national origin, disability, age,
sex, and in some cases religion or political beliefs.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights
regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or
administering USDA programs are prohibited from discriminating based on race,
color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation for prior
civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g.
Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local)
where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may
contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may
be made available in languages other than English.
To file a program complaint of discrimination, complete the
USDA Program Discrimination Complaint
Form,
(AD-3027) found online at:
How to File a
Complaint, and at any USDA office, or write a letter addressed to
USDA and provide in the letter all of the information requested in the form. To request a copy of the
complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
(1) mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
(2) fax: (202) 690-7442; or
(3) email:
program.intake@usda.gov.
For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons
should either contact the USDA SNAP Hotline Number at (800) 221-5689, which is also in Spanish or call
the
State Information/Hotline Numbers
(click the link for a listing of hotline numbers by State); found online
at:
SNAP
Hotline.
To file a complaint of discrimination regarding a program receiving Federal financial assistance through the
U.S. Department of Health and Human Services (HHS), write: HHS Director, Office for Civil Rights, Room
515-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (voice) or (800)
537-7697 (TTY).
This institution is an equal opportunity provider.
BFA SR 19-29
(3YC)
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