ࡱ> ?w<=> @ bjbj5*5* 8W@W@8\nynyny8 ,y8~"hC_$ڤR,h͐͐͐͐͐͐:,͑  jxnya> ђ~0Ñ ّّh͐T=~d@ Pd) PAUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATIONClient NameMichigan Department of Human Services FORMTEXT        FORMTEXT      Case NumberClient ID Number FORMTEXT       FORMTEXT      MaleFemaleClient s Date of Birth FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      CountyDistrictSectionUnitWorkerTO: FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT   Worker Name FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT      Telephone Number/ext. FORMTEXT       FORMTEXT      FORMTEXT        FORMTEXT      FORMTEXT        FORMTEXT     FORMTEXT      SECTION 1:I authorized you to release the named adult and/or minor childs information as described below. The type and amount of information to be released is as follows:REQUESTED INFORMATION  FORMCHECKBOX MEDICAL RECORDS OF: FORMTEXT (insert names here) FORMTEXT      Physical examinations and clinical evaluations including any information relative to HIV, ARC or AIDS if applicable. Treatment for any physical illness. Medical records, including admitting histories, discharge summaries, laboratory reports, test results, diagnosis, complications, progress notes, medications, workshop evaluations, training reports, treatment plans, prognosis, recommendations and current status. FORMCHECKBOX MENTAL HEALTH RECORDS OF: FORMTEXT (insert names here) FORMTEXT      Treatment for any emotional illness, psychiatric or psychological reports, IQ scores, diagnosis, progress notes, medications, treatment plans, prognosis, recommendations and current status. FORMCHECKBOX SUBSTANCE/ALCOHOL ABUSE RECORDS OF: FORMTEXT (insert names here) FORMTEXT      Treatment for any drug or alcohol abuse, laboratory reports, test results, diagnosis, complications, progress notes, medications, treatment plans, prognosis, and current status. FORMCHECKBOX EDUCATIONAL RECORDS OF: FORMTEXT (insert names here) FORMTEXT      School records including progress reports, attendance, special education and other evaluations. FORMCHECKBOX OTHER (Specify) OF: FORMTEXT (insert names here) FORMTEXT       FORMCHECKBOX OTHER (Specify) OF: FORMTEXT (insert names here) FORMTEXT      I understand that this information may include, when applicable, information relating to sexually transmitted disease, Human Immunodeficiency Virus (HIV infection, Acquired Immune Deficiency Syndrome or AIDS Related Complex) and any other communicable disease. It may also include information about behavioral or mental health services, and referral or treatment for alcohol and drug abuse (as permitted by 42 CFR Part 2).This information may be released during the course of business to organizations that regularly review child welfare cases including Office of Childrens Ombudsman, Foster Care Review Board, Citizens Review Panel, Friend of the Court, County Medical Examiner, law enforcement, and Child Fatality Review Team.SECTION 2:This information may be released to and used by the following: FORMCHECKBOX  FORMTEXT      County Department of Human Services FORMCHECKBOX Attorney Representing Mother FORMTEXT       FORMCHECKBOX Attorney Representing FatherAddress (Street) FORMCHECKBOX Lawyer  Guardian Ad Litem Representing Child(ren) FORMTEXT        FORMTEXT     FORMTEXT       FORMCHECKBOX Service Provider (specify) FORMTEXT      Address (City, State, Zip Code) FORMCHECKBOX Service Provider (specify) FORMTEXT      ( FORMTEXT    )  FORMTEXT      ( FORMTEXT    ) FORMTEXT       FORMCHECKBOX Service Provider (specify) FORMTEXT      Phone NumberFax Number FORMCHECKBOX Court Appointed Special Advocate (CASA) FORMCHECKBOX  FORMTEXT      County FamiNhv     ` b v x z   " $ @ B D F H \ |jhovhFR5Ujh%5Uj3hFRUjh%U h%5jh\Ujh\Ujh\UjhovUmHnHujh\UjhHUhjhHh%hD0h f`Z%$If-$IfOkdX$$Ifl40e+*.4 laf4.$If<kd$$Ifl40+<-*.4 laf4$Ifj/ " : \ ^ ` @:-$Ifbkd2$$Ifl4Fe$+IC*.    4 laf4$If $IfOkd$$Ifl40e+*.4 laf4` $Ifgd%-$Ifbkd$$Ifl4Fe$+IC*.    4 laf4%$If " F n ysgg^ %$IfgdH %$$Ifa$gd%-$Ifkd@$$Ifl4\e !$+C*.4 laf4p\ ^ ` j l n p    " $ ( * , . 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FORMCHECKBOX Other (Specify) FORMTEXT      (NOTE: The statement  at the request of the individual is sufficient when the individual initiates an authorization and does not, or chooses not to, state the purpose.)I understand that if I give DHS permission I have the right to change my mind and revoke it. This must be in writing to : FORMTEXT       County Department of Human Services. I also understand that DHS cannot take back any uses orreleases already made with my permission.Unless otherwise revoked, this authorization will expire on the following date, event or condition. (If I fail to specify an expiration date, event or condition, this authorization will expire one year from the signature date): FORMCHECKBOX Court jurisdiction dismissed FORMCHECKBOX Children s services case closed FORMCHECKBOX Other (specify) FORMTEXT      I understand that release of this information is voluntary. I also understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment.By signing this Authorization, I understand that any release of information carries with it the potential for an unauthorized release and the information may not be protected by federal privacy rules. I further understand I may request a copy of this signed authorization.Printed Name of Client (or Legal Representative)Printed Name of Witness (Worker) FORMTEXT       FORMTEXT      Signature of Client (or Legal Representative)DateSignature of Witness (Worker)Date FORMTEXT       FORMTEXT      If signed by Legal Representative, Relationship to Client:(A letter of authority may be requested) FORMTEXT      DHS USE ONLYThis authorization was revoked: FORMTEXT      SignatureDateAUTHORIZATION:This authorization is valid only for the purpose, information, agencies and persons cited above. This information release authorization has been prepared in accordance with the authority specified below: 42 CFR, part 2, subpart C, Section 2.31, as revised August 10, 1987 1978 PA 368 1978 PA 238 1974 PA 258This authorization form is acceptable to the Michigan Department of Human Services as compliant with HIPAA privacy regulations 45 CFR Parts 160 and 164.Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area. PAGE  PAGE 1 DHS-1555-CS (Rev. 2-09) MS Word XZ\~ʴ̴δдҴ02NPRTrtvȵֵz|輸ϼ襡襡ϥ臃{pjwhFRUhuh:5h:hj shg1%UjrhFRUhg1%jhg1%Ujqh\Uh\jh\UjphFRUjhovUmHnHujNnhUhfbRjhfbRUj\mhFRU,$Ifkdo$$Ifl4(ִ P n+,t w *.    4 laf4pFд0Tt %$Ifgdg1%$If $Ifgdd8$If]^gds %$Ifgd %$Ifgd}{=7* %$Ifgd$IfkdGt$$Ifl4(ִ P n+,t w *.    4 laf4$If $Ifgd d8$Ifgd %$Ifgdʵ=7. $Ifgd:$Ifkdiu$$Ifl4pִ v n+,t w *.    4 laf4ʵ̵εеҵԵֵ5kdv$$Ifl4P֞ v n+,tj w *.4 laf4$If $Ifgd d8$Ifgdֵصvxz $Ifgdg %$IfgdjOkd{w$$Ifl4=0 +t**.4 laf4$If$IfԷַط@BDFZ\^hj(*RTVXtvxҽԽֽ:źŏyj}hFRUji}hFRU)jhov5CJOJQJUmHnHu*j{hsh\5CJOJQJUhfbR5CJOJQJjhfbR5CJOJQJU hfbR5jhovUmHnHujcxhfbRUhfbRjhfbRU,zqz $Ifgdg %$Ifgdj$Ifukdx$$Ifl4 \ h+tl#*.4 laf4HJL}-Okd3z$$Ifl430 +t**.4 laf4$If$Ifukdy$$Ifl4p\ h+tl#*.4 laf4L@BDn(*,@bkd{$$Ifl4F  +t B *.    4 laf4$IfOkdz$$Ifl40 +t**.4 laf4$If,RSOkd|$$Ifl4p0 +t**.4 laf4$IfOkd|$$Ifl40 +t**.4 laf4$IfRTVzؽ %$IfgdH$If %$Ifgd9$IfOkd|$$Ifl4 0 +t**.4 laf4@`vpc]T %$Ifgd&$If %$Ifgd9$IfkdQ~$$Ifl4r n?+`t*.4 laf4:<>`bvxz$&*,PR$&,.BDFPRTVX "$&028¾϶϶{φj@h$Ujh$U h$5h$ h'5jh\Uj*h\UhsjhsUh'h;h;5 hfbR5jhovUmHnHujzhfbRUhfbRjhfbRUjhFRU0vpg %$Ifgd&$If %$Ifgd9$Ifukd$$Ifl4\ h+ tl#*.4 laf4$&(}-OkdE$$Ifl4 0 +t**.4 laf4$If$Ifukd$$Ifl4p\ h+tl#*.4 laf4(*,.PRTSOkd!$$Ifl40 +t**.4 laf4$IfOkd$$Ifl4p0 +t**.4 laf4$If (*,TVPGG %$Ifgds$Ifkd$$Ifl4 r cns+tW a*.4 laf4p2$IfTVX\VPDPP $$Ifa$gd$$If$Ifkd$$Ifl4r cns+tW a*.4 laf4p2 8/& %$Ifgd$ $Ifgd'kd$$Ifl4 ֈ ns%+t*.4 laf4p< $$Ifa$gd; 468`b2kd$$Ifl4ֈ ns%+t*.4 laf4p< $Ifgd' %$Ifgd$8:NPR\^`bd.68:<PRT^`bdjl$*,24VXZոګh'hfbRCJ aJ hfbROJQJjhfbRUjhfbRU hfbR5hfbRj{h$U hs5 h'5h' h$5jhovUmHnHujh$Uh$jh$U7bd0246[kd$$Ifl4 0 +t**.4 laf4p $Ifgd' $Ifgd'68:b\SJ %$Ifgd\ $Ifgd'kd^$$Ifl4 r cns+tW a*.4 laf4p2bdfhjln5bkd$$Ifl4 F (+ *.d    4 laf4$If$If[kd$$Ifl40 +t**.4 laf4pn$Ifbkd-$$Ifl4PF ^B)+R&*.t    4 laf4$If0$If %$IfgdH$If$Ifbkd$$Ifl4F ^B)+R&*.t    4 laf4"}}$If$Ifukd$$Ifl4 \ ^5)+R( *.t4 laf4"$&(*,-bkd$$Ifl4pF ^B)+R&*.t    4 laf4$If$Ifbkd$$Ifl4F ^+R2D *.t    4 laf4,.0246TVbkd8$$Ifl4pF !*,)(*.t    4 laf4$If$IfVXZ|{nnnn  & Fd$$Ifd$Ifgd'$If d$Ifbkd$$Ifl4F !*,)(*.t    4 laf4 $$Ifa$$If $$Ifa$bkdJ$$Ifl4pF O5)+C%*.t    4 laf4dfhjlxz|   & ( * > @ B L N Ͼϋti[jh}UmHnHujh}UjӔh}Uh}jh}UhFRhgzCJaJh9hgzCJaJhFR0J8CJaJmHnHuh9hgz0J8CJaJ!jh9hgz0J8CJUaJhgz hgz0J8jhgz0J8U hHCJhB:hfbRCJ^JaJhfbR hfbR5#fhj|~QOCAO* *&`#$gdH<kdb$$Ifl4x *~)*.t84 laf4$$Ifa$gd:bkdٓ$$Ifl4PF O5)+C%*.t    4 laf4( P x    !:!^!!!!! "H"j"" * d`gd9*d`&`#$gd9/ =!"#h$h%V$$If!vh5<-#v<-:V l40*.5<-4af4$$If!vh55#v#v:V l4*.55/ /  4af4DGranteeFirstName=Enter the Grantee's First Name (and Middle Initial, if known)DGranteeLastNameEnter the Grantee's Last Name$$If!vh55#v#v:V l4*.55/ / 4af4$$If!vh55I5C#v#vI#vC:V l4*.55I5C/ /  /  / 4af4D CaseNumber UPPERCASE/Enter the Case Number (Example: V1234567A,B,C)D OtherID UPPERCASE9 digit maximum$$If!vh55I5C#v#vI#vC:V l4*.55I5C/ / / /  4af4$$If!vh5555C#v#v#v#vC:V l4*.5555C/ /  /  / 4af4ptDeMCheckDeFcheckCheck appropriate box.D Birthdate MM/DD/YYYY$$If!vh5555C#v#v#v#vC:V l4*.5555C/ /  / / 4af4p$$If!vh555555#v#v#v#v:V l4*.5555/ /  4af4D CountyNumberEnter the County Number. DDistrictEnter the District Number. DSectionEnter the Section Number. DUnitEnter the Unit Number. DWorkerEnter the Worker Number. $$If!vh5t5Y55555#vt#vY#v#v#v:V l4*.5t5Y555/ /  4af4$$If!vh5t5555#vt#v#v#v#v:V l4*.5t5555/ / /  4af42DFName_Enter the Addressee's First Name (and Middle Initial, if known). Then, tab to Last Name Field.DLNameEnter the Addressee's Last NameD WorkerName-Enter the Specialist's/Services Worker's Name$$If!vh5t555#vt#v#v#v:V l4*.5t555/ / / 4af4$D"SuppAddrUEnter the Addressee's Supplemental Address (Example: Suite or Apartment Number, C/O)$$If!vh5t555#vt#v#v#v:V l4*.5t555/ / /  4af4FD" StreetAddrdEnter the Addressee's mail address (street address, PO Box, etc., where the mail will be delivered).DWorkerAreaCodeEnter the Area Code.D WorkerPhone2Enter the 7 digit phone number (Example: 373-1234)DWorkerExtension5Enter the extension number, if any, (Example: X12345)$$If!vh5t555#vt#v#v#v:V l4*.5t555/ / / 4af4DCityEnter the Addressee's City.DState Uppercase1Enter the Addressee's 2 digit State Abbreviation.D ZipKEnter the Addressee's Zip Code (+4 if known) (Example: 48909 or 48909-7537)$$If!vh5t555#vt#v#v#v:V l4*.5t555/ / / 4af4$$If!vh5t5555#vt#v#v#v#v:V l4 *.5t5555/ / / / / 4af4$$If!vh5t5]5#vt#v]#v:V l4*.5t5]5/ 4af4$$If!vh5t5]5k#vt#v]#vk:V l4*.5t5]5k/ 4af4w$$Ifx!vh5*5#v*#v:V l4p*.t,5*54af4q$$Ifx!vh5*5#v*#v:V l4p*.t5*54af4$$If!vh5t5(5#vt#v(#v:V l4`*.+5t5(5/ 4af4$$If!vh5t5*5#vt#v*#v:V l4*.+,5t5*5/  / 4af4pDe CheckProv:Check box and specify what specific information is needed.DA(insert names here)$$If!vh5t55E 55#vt#v#vE #v#v:V l4 *.,,5t55E 55/ / /  / 4af4p($$If!vh5t55E 55#vt#v#vE #v#v:V l4*.,,5t55E 55/ /  / / 4af4p(tDUText5 $$If!vh5t55 )5#vt#v#v )#v:V l4 *.,,5t55 )5/ / / /  / 4af4p $$If!vh5t55 )5#vt#v#v )#v:V l4*.,,5t55 )5/  / /  / / 4af4p$$If!vh5t5*5#vt#v*#v:V l4*.,5t5*5/  / 4af4pDe CheckProv:Check box and specify what specific information is needed.D<(insert names here)$$If!vh5t55 55#vt#v#v #v#v:V l4 *.,,5t55 55/ / /  / 4af4p($$If!vh5t55 55#vt#v#v #v#v:V l4*.,,5t55 55/ /  / / 4af4p(tDUText5 $$If!vh5t55 )5#vt#v#v )#v:V l4 *.,,5t55 )5/ / / /  / 4af4p $$If!vh5t55 )5#vt#v#v )#v:V l4*.,,5t55 )5/  / / / / 4af4p $$If!vh5t55 )5#vt#v#v )#v:V l4 *.,,5t55 )5/  / / / / 4af4pDe CheckProv:Check box and specify what specific information is needed.D1(insert names here)$$If!vh5t555G5#vt#v#v#vG#v:V l4 *.,,5t555G5/ / /  / 4af4p($$If!vh5t555G5#vt#v#v#vG#v:V l4*.,,5t555G5/ /  / / 4af4p(tDUText5 $$If!vh5t55 )5#vt#v#v )#v:V l4 *.,,5t55 )5/ / / /  / 4af4p$$If!vh5t55 )5#vt#v#v )#v:V l4*.+,,5t55 )5/  / / / / 4af4p$$If!vh5t55 )5#vt#v#v )#v:V l4 *.+,,5t55 )5/  / / / / 4af4pDe CheckProv:Check box and specify what specific information is needed.D=(insert names here)$$If!vh5t55= 55#vt#v#v= #v#v:V l4 *.,,5t55= 55/ / /  / 4af4p($$If!vh5t55= 55#vt#v#v= #v#v:V l4*.,,5t55= 55/ /  / / 4af4p(tDUText5 $$If!vh5t55 )5#vt#v#v )#v:V l4 *.,,5t55 )5/ / / /  / 4af4p $$If!vh5t55 )5#vt#v#v )#v:V l4*.,,5t55 )5/  / / / / 4af4pDe CheckProv:Check box and specify what specific information is needed.DE(insert names here)$$If!vh5t555P!5#vt#v#v#vP!#v:V l4 *.,,5t555P!5/ / /  / 4af4p($$If!vh5t555P!5#vt#v#v#vP!#v:V l4*.,,5t555P!5/ /  / / 4af4p(tDUText5'$$If!vh5t55 )5#vt#v#v )#v:V l4 *.,,5t55 )5/  / / / / /  / 4af4p$$If!vh5t555b!5#vt#v#v#vb!#v:V l4*.,5t555b!5/ / /  / / / 4af4De CheckProv:Check box and specify what specific information is needed.DE(insert names here)$$If!vh5t555P!5#vt#v#v#vP!#v:V l4 *.,,5t555P!5/ / /  / 4af4p($$If!vh5t555P!5#vt#v#v#vP!#v:V l4*.,,5t555P!5/ /  / / 4af4p(tDUText5 $$If!vh5t55 )5#vt#v#v )#v:V l4 *.,,5t55 )5/ / / /  / 4af4p$$If!vh5t555 5#vt#v#v#v #v:V l4*.,5t555 5/ /  / / 4af4$$If!vh5t5*5#vt#v*#v:V l4p*.5t5*5/ / 4af4$$If!vh5t5*5#vt#v*#v:V l4*.,5t5*5/ 4af4$$If!vh5t5*5#vt#v*#v:V l4p*.,5t5*5/ 4af4$$If!vh5t5*5#vt#v*#v:V l4*.,,5t5*5/ 4af4V$$If!vh5.+#v.+:V l4p*.5.+4af4$$If!vh5t5*5#vt#v*#v:V l4(*.,5t5*5/ 4af4$$If!vh5t5*5#vt#v*#v:V l4(*.,5t5*5/ 4af4De CheckOther2:Check box and specify what specific information is needed.D CoName UPPERCASEEnter the County's Name.De CheckOther2:Check box and specify what specific information is needed.$$If!vh5t55Q5R 5w55#vt#v#vQ#vR #vw#v#v:V l4(*.,5t55Q5R 5w55/ 4af4>D( UPPERCASEaEnter the County's mail address (street address, PO Box, etc., where the mail will be delivered).De CheckOther2:Check box and specify what specific information is needed.$$If!vh5t555w55#vt#v#v#vw#v#v:V l4(*.,5t555w55/ 4af4De CheckOther2:Check box and specify what specific information is needed.$$If!vh5t555w55#vt#v#v#vw#v#v:V l4(*.,5t555w55/ 4af4D UPPERCASEEnter the County's City.DCoState UPPERCASE-Enter the County's 2 digit State AbbreviationD CoZip UPPERCASEDEnter the County's Zip (+4 if known) (Example: 48909 or 48909-7537)De CheckOther2:Check box and specify what specific information is needed.PD CoAddress LOWERCASEaEnter the County's mail address (street address, PO Box, etc., where the mail will be delivered).$$If!vh5t555w5' 5 5#vt#v#v#vw#v' #v #v:V l4(*.,5t555w5' 5 5/ / 4af4De CheckOther2:Check box and specify what specific information is needed.>D LOWERCASEaEnter the County's mail address (street address, PO Box, etc., where the mail will be delivered).$$If!vh5t555w5' 5 5#vt#v#v#vw#v' #v #v:V l4(*.,5t555w5' 5 5/ / 4af4vDCoAreaxDCoPhonexDFaxAreazDFaxPhoneDe CheckOther2:Check box and specify what specific information is needed.>D LOWERCASEaEnter the County's mail address (street address, PO Box, etc., where the mail will be delivered).$$If!v h5t555H555w5' 5  5 #vt#v#v#vH#v#v#vw#v' #v #v :V l4(*., 5t555H555w5' 5  5 / / /  / 4af4pZ)kdbc$$Ifl4( P n !+,tHw'  *.((((4 laf4pZDe CheckOther2:Check box and specify what specific information is needed.$$If!v h5t555H555w55 #vt#v#v#vH#v#v#vw#v#v :V l4(*., 5t555H555w55 / / /  4af4pPkd8h$$Ifl4( P n+,tHw*.$$$$4 laf4pPDe CheckOther2:Check box and specify what specific information is needed.D UPPERCASEEnter the County's Name.De CheckOther2:Check box and specify what specific information is needed.>D LOWERCASEaEnter the County's mail address (street address, PO Box, etc., where the mail will be delivered).i$$If!vh5t555 5w55 5#vt#v#v#v #vw#v#v #v:V l4(*.,5t555 5w55 5/ / / 4af4pFDe CheckOther2:Check box and specify what specific information is needed.D UPPERCASEEnter the County's Name.tDeCheck5>D LOWERCASEaEnter the County's mail address (street address, PO Box, etc., where the mail will be delivered). $$If!vh5t555 5w55 5#vt#v#v#v #vw#v#v #v:V l4(*.,5t555 5w55 5/ / / 4af4 $$If!vh5t555 5w55 5#vt#v#v#v #vw#v#v #v:V l4p*.,5t555 5w55 5/ / / 4af4$$If!vh5t5j5 5w55 5#vt#vj#v #vw#v#v #v:V l4P*.,5t5j5 5w55 5/ 4af4r$$If!vh5t5*#vt#v*:V l4=*.,5t5*4af4tDeCheck4tDIText4$$If!vh5t555l##vt#v#v#vl#:V l4 *.,5t555l#/ 4af4$$If!vh5t555l##vt#v#v#vl#:V l4p*.,5t555l#/ 4af4l$$If!vh5t5*#vt#v*:V l43*.5t5*4af4l$$If!vh5t5*#vt#v*:V l4*.5t5*4af4~D CountyName$$If!vh5t5 5B #vt#v #vB :V l4*.5t5 5B / 4af4l$$If!vh5t5*#vt#v*:V l4*.5t5*4af4l$$If!vh5t5*#vt#v*:V l4p*.5t5*4af4l$$If!vh5t5*#vt#v*:V l4 *.5t5*4af4tDeCheck2tDeCheck2$$If!vh5t5555#vt#v#v#v#v:V l4*.+5t55554af4tDeCheck2jDI$$If!vh5t555l##vt#v#v#vl#:V l4*.+,5t555l#/ 4af4$$If!vh5t555l##vt#v#v#vl#:V l4p*.,5t555l#/ 4af4l$$If!vh5t5*#vt#v*:V l4 *.5t5*4af4l$$If!vh5t5*#vt#v*:V l4p*.5t5*4af4z$$If!vh5t5*#vt#v*:V l4*.5t5*/ 4af4$$If!vh5t5W5 55a#vt#vW#v #v#va:V l4 *.5t5W5 55a/  / /  / / /  / / /  / / /  4af4p2tD)Text9jD)$$If!vh5t5W5 55a#vt#vW#v #v#va:V l4*.,,5t5W5 55a/ / / / / / / / / / / /  4af4p2$$If!vh5t55555#vt#v#v#v#v#v:V l4 *.5t55555/  / /  / / /  / / / /  / 4af4p<jD tD Text7$$If!vh5t55555#vt#v#v#v#v#v:V l4*.5t55555/ / / / / / / / / /  / 4af4p<$$If!vh5t5*#vt#v*:V l4 *.5t5*/  / 4af4p$$If!vh5t5W5 55a#vt#vW#v #v#va:V l4 *.5t5W5 55a/  / / / 4af4p2tDYText8$$If!vh5t5*#vt#v*:V l4*.,5t5*/ / 4af4p$$Ifh!vh555 #v#v#v :V l4 *.d555 / 4af4$$Ifx!vh5R5&5#vR#v&#v:V l4P*.t,5R5&5/ /  / 4af4$$Ifx!vh5R5&5#vR#v&#v:V l4*.t5R5&5/ / 4af4jD$$Ifx!vh5R5(5 5#vR#v(#v #v:V l4 *.t,5R5(5 5/ / /  / / 4af4$$Ifx!vh5R525D #vR#v2#vD :V l4*.t5R525D / / 4af4$$Ifx!vh5R5&5#vR#v&#v:V l4p*.t5R5&5/ /  / 4af4$$Ifx!vh55)(5#v#v)(#v:V l4p*.t55)(54af4$$Ifx!vh55)(5#v#v)(#v:V l4*.t55)(54af4$$Ifx!vh5C5%5#vC#v%#v:V l4p*.t,5C5%54af4$$Ifx!vh5C5%5#vC#v%#v:V l4P*.t5C5%54af4o$$Ifx!vh5~)#v~):V l4x*.t8,5~)/ 4af4DAddress1 UppercasedEnter the Addressee's mail address (street address, PO Box, etc., where the mail will be delivered). 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CJOJQJNON Form Title 10pt+$d8a$OJQJZOZ Form Title 10pt Bld,$d8a$ 5OJQJROR Form Title 11pt-$d$a$ CJOJQJLOL Form Title 11pt Bld.d$CJROR Form Title 12pt/$da$ CJOJQJ^O^ Form Title 12pt Bld0$da$5CJOJQJ4@4 Header 1 !PO"P Letter Text 10pt2$d$a$OJQJFO!2F Letter Text 11pt3dCJTOBT Letter Text 12pt4$da$ CJOJQJHORH Small Blank Line 5CJPObP User Input 11pt6d$5CJOJQJXOrX User input 12pt7d((5CJOJQJ.)@. 9 Page NumberFV@F FollowedHyperlink >*B* ph\O\ % User Input 10pt Char5OJQJ_HmH sH tH XOX  Captions 9pt CharCJOJQJ_HmH sH tH HH \ Balloon Text<CJOJQJ^JaJ 4@Ag#789@IQV]^_ct  567KL     !?@ABCDEFGHI]^_`a-Eghijklmnopq 4 5 6 7 8 9 : ; < = > R S T U V W X Y Z [ m u v w x y z { |      , P b  !"#$]o/0WXjBTdxyz{    EFG\123EUijklmnop789:;<MNO#()*+?@AUVW  $%&'16789:;<=>?@OPQRco{#$%0 0$ .0 0 0$ -0 %0 0$ 0 0 0 0$ -0 %0 %0 0$ -0 0 0 0 0$ -0 %0 %0 %0 0$ 0 0 0 0 0 0 0$ 0 0 %0 %0 %0 %0 %0 0$ 0 0 0 0 0 0$ 0 %0  0 %0 0$ 0 %0  0 0 0$ 0 %0  0 %0 0$ 0 %0  0 0 0$ 0 %0 %0 %0 0 0$ 0 0 0 0$ 0 0 0 0$ 0 0 0$ 0 0 0$ 0 0 0 0$ 0 0 0 0 0$ 0 %0 %0 %0 %0 0$ 0 %0 %0 %0 %0 0$ 0 %0 %0 %0 0$ 0 %0 0 %0 0$ 0 0 0 0$ 0 %0 %0 %0 %0 0$ 0 %0 %0 %0 %0 0$ 0 %0 %0 %0 0$ 0 %0 0 %0 0$ 0 %0 0 %0 0$ 0 %0 %0 %0 %0 0$ 0 %0 %0 %0 %0 0$ 0 %0 %0 %0 0$ 0 %0 0 %0 0$ 0 %0 %0 %0 0$ 0 %0 %0 %0 %0 0$ 0 %0 %0 %0 %0 0$ 0 %0 %0 %0 0$ 0 %0 0 %0 0$ 0 %0 0 %0 %0 0$ 0 %0 %0 %0 %0 0$ 0 %0 %0 %0 0$ 0 %0 0 %0 %0 0$ 0 %0 0 %0 %0 0$ 0 %0 %0 %0 %0 0$ 0 %0 %0 %0 0$ 0 %0 0 %0 %0 0$ 0 0 0 0$ 0 0 0 0$ 0 0 0 0$ 0 0 0 0$ 0 0$ 0 0 0 0$ 0 0 0 0$ 0 %0 %0 0 %0 0 0 0$ 0 %0 %0 %0 0 0 0 0 %0 0 %0 0 0 0 0 %0 %0 %0 0 %0 0 0 0 %0 0 %0 0 %0 0 0 0 %0 %0 0 %0 0 %0 0 %0 0 0 0 %0 0 0 0 0 %0 0 0 0 0 %0 %0 0 %0 0 %0 0 0 0 %0 %0 0 0 0 %0 0 0 0 %0 %0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 %0 0 %0 0 0 %0 0 %0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 %0 0 %0 0 0 0 %0 0 %0 0 0 %0 0 %0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 %0 0 0 %0 0 0 0 0 0 0 0 0 0 %0 %0 0 0 %0 0 0 0 0 0 0 0 0 0 0 0 %0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 %0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0@*0@*0@0@*0@*0@00S4@Ag#789@IQV]^_ct  567KL@F^_-Ehno 5 6 ; < S T U V W X Y Z [ m u v w x y z { |     , b  !"]o/WjBTdxyzEFG\123EUijp789:;<MNO#(*AU  $%&'16789:;<=>?@OPQRco{#$%@.0 @0 @0 @-0 @%0 @0 @ 0 @0 @0 @0 @-0 @%0 @%0 @0 @-0 @0 @0 @0 @0 @-0 @%0 @%0 @%0 @0 @ 0 @0 @0 @0 @0 @0 @0 @ 0 @ 0 @%0 @%0 @%0 @%0 @%0 @0 @ 0 @ 0 @ 0 @ 0 @0 @0 @ 0 @%0 @ 0 @%0 @0 @ 0 @%0 @ 0 @0 @0 @ 0 @%0 @ 0 @%0 @0 @ 0 @%0 @ 0 @ 0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0@0 `0 @0 @0 @%0 @0 @%0 @0 A0Y0H@%0 @0 @%0 @0 @%0 A0d0|@0A0d0|@0 @0 @%0 @0 @%0 A0d0A0d0@0 A008 $A008 1A008 1 @0x @0 @%0 @0 @%0 A0d0@0A0d0@0 A00 [ @0u @0 @%0 @0 @%0 @0 A00P@%0A00P@%0 @ 0 @%0 @0 @%0 @%0 @0 @0 @%0 @0 @%0 @0 A00@0A00@0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @%0 @%0 @%0 @0 @00t@0 @%0 @%0 @0 @00t@0 @0 @%0 @0 @00t@0 @%0 @%0 @0 @%0 @00t,@0 @0 @%0 @0 @%0 @00tH@%0 @%0 @%0 @%0 @0 @%0 @00t@0 @0 @0 @%0 @00tD@%0 @%0 @%0 @0 @%0 @0 @%0 @00t@%0 @%0 @%0 @0 @00"0q@0 A00@0 A00@0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @%0 @0 @%0 @0 @0 `0 @%0 @0 @%0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 A00lPA00làA00lA00làA00lA00)t=@0 A00lA00)A01$A01$A01$@0 A00l@0 @0 @0 @0 @0 @00 @0 @0 @0 @0 @0 @0 @0 @0 @%0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @ 0 @0@0@ 0@ 0@ 0@ 0 @0 @0 @0 @0 @0 @0 @0 @0 0} 777:gsy{!#/5cort 7CILX\^jpr~ )=IU[+EQeq}  2 > J P [ k    $ * P ` $068DGIU[]m'-1=ACOUXhBRdpv{GSY3CUag+7=AMS"F4F4F4F4G G FFFFFFFFF4FFFFFtFFFG$FFG$FFG$FFG$FFG$FFG$FFG$FG$FG$G$FFFG$FG$FFFFFG$FG$G$FG$FG$FG$FG$FFG$G$G$FFFFFFF :!!8@0( 8 B S  ?#GranteeFirstNameGranteeLastName CaseNumberOtherIDMCheckFcheck Birthdate CountyNumberDistrictSectionUnitWorkerFNameLName WorkerNameSuppAddr StreetAddrWorkerAreaCode WorkerPhoneWorkerExtensionCityStateZipText5CoName CoAddressCheck5Check4Text4 CountyNameCheck2Text10Text9Text7Text8h|$du 8M_s HB  !"z"6sJ]q+ ZT Jk\^Kkt|Lk$MkT#Nk|Ok|oPk4|QkI\*+Efq 3 > Q j k    + _ ` $78HI\lm.1BCVghQRdwGZBCUh+>AT#\ `S@  hh^h`OJQJo( hh^h`OJQJo(\`S@ 87p$OD _X}{N;y'A%g1%Y*59~HCL NfbR\OEfwgGiGprszuovqZy &Vz%IugzI vD9R{EFR! H+5jj:g; 0 4@Ag#789@IQV]^_ct  567KL     !?@ABCDEFGHI]^_`a-Eghijklmnopq 4 5 6 7 8 9 : ; < = > R S T U V W X Y Z [ m u v w x y z { |      , P b  !"#$]o/0WXjBTdxyz{    EFG\123EUijklmnop789:;<MNO#()*+?@AUVW  $%&'16789:;<=>?@OPQR#$%@ tyH1tt  % %%% @$@8@ "$UnknownG: Times New Roman5Symbol3& : Arial?5 z Courier New5& zaTahoma"hjfjffN4N4r ci#4dO2QH(?0 >DHS-1555-CS, Authorization to Release Confidential InformationComp martinezl  Oh+'0  4@ \ h t @DHS-1555-CS, Authorization to Release Confidential InformationCompDHS-1555-CS.dot martinezl2Microsoft Word 10.0@@vD@L8x@L8xN՜.+,08 hp  State of Michigan4 ?DHS-1555-CS, Authorization to Release Confidential Information Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~AQ      !"#$%&'()*+`-./012356789:;@BCDEFGHIJKLMNOPRSTUVWXYZ[\]^_abcdefghijklmnopqrstuvRoot Entry FnxxData 1TableWordDocument8SummaryInformation(,DocumentSummaryInformation84CompObjj @  /bjbj5*5* 8W@W@̹E &,R")|$RR-eeeeeeeeeeee jx̹ee 0&eeeeeeeeeeee$̹e̹ FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT        FORMTEXT        FORMTEXT      FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT      FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEN P R f h v x z                !!!!!(!*!8!:!#@#N#P#R#f#h#v#x#z##################$,,,,,,.,jѦh}UUjh}Uj|h}Ujh}Ujǣh}Ujh}Uj+h}Ujh}UmHnHujh}Uh}jh}U2XT        FORMTEXT        FORMTEXT     FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT      FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT     FORMTEXT      FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       .,0,>,@,B,V,X,`,b,d,x,z,,,,,,,,,,,,,,,,------ -"-$-&-:-<->-D-F-H-J-^-`-n-p-r--jrh}Ujh}Ujh}UmHnHujh}Ujyh}Ujh}Ujoh}Ujh}Uj h}Uh}jh}Ujh}U1--------------------.......$.&.(.*.>.@.N.P.R.f.h.v.x.z............jh}Ujhh}Ujh}Ujgh}Ujh}Ujh}Ujh}UmHnHujWh}Ujԭh}Uh}jh}Ujh}U3(.P.x....//=<;:98.......// ////jh}UmHnHuj{h}Ujղh}Uh}jh}U / =!"#$%reau#Enter your Bureau/Office/Unit name.DCareOf UppercaseUEnter the Addressee's Supplemental Address (Example: Suite or Apartment Number, C/O)Address1D CaseNumber Uppercase/Enter the Case Number (Example: V1234567A,B,C)D ClientCity UppercaseEnter the Addressee's City. 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