1h. DSHS Benefit Verification Consent Form Procedure

• Created 03/25

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Procedure

This form provides consent to use or share confidential benefit verification information about a client between DSHS and Lower Columbia College Head Start/EHS/ECEAP.

How to Use:

1. Fill out this form electronically if possible. You must complete a separate form for each person, including children, if necessary.
2. Name: Provide the name of only one client on each form. Include any former names that client may have used when receiving services
3. Date of Birth: Needed to identify clients from persons with similar names.
4. Identification Number: Provide a client identification number or other identifier such as a social security number (not required) to assist in identifying records and tracking history and services received.

Consent Authorization:

1. Reason for disclosure: This information is required before DSHS can share verification of SNAP/TANF benefits.
2. Agencies or persons exchanging records:
   This completed form allows:
   1. the use and disclosure of confidential information inside DSHS and with the agencies or persons listed; and
   2. disclosure of confidential information to DSHS by the outside agencies or persons listed. You may also attach a list of agencies allowed to share information, which the client must also sign.
3. Information included: Clients must indicate what records are covered by the consent. Clients may make all records available or may limit the included records by date, type or source of record. If a client does not sign a consent or does not specify a particular record, sharing of that record will still be allowed if permitted by law. You may attach a list of covered records that the client must also sign.
4. Duration: Include an expiration date for the consent, if different than one year. The consent will expire in one year unless you identify a different date.
5. Understanding: Be sure the client understands what permission is being granted and how and why information will be shared. If needed, use a translated form and interpreter or read the form aloud. If the client needs more information, provide an additional copy of the DSHS Notice of Privacy Practices.

Signatures:

1. Client: Have the client sign this box and insert the date of signature. The client may substitute a mark in this box that you witness.
2. Witness or Notary: A witness or notary may be needed to verify the client’s identity if the client does not submit this form in person or if a program requests verification. This person should sign and print his or her name.
3. Parent or Other Representative: If the client is a child under the age of consent, a parent or guardian must sign. If the child does not meet the age of consent for all records to be shared, both the child and the parent must sign. If someone is signing in another capacity (including a person with a power of attorney or an estate representative), mark “other” and obtain a copy of the legal authority to act. The person signing must date the signature and give a telephone number or contact information.

Use of DSHS BVS System:

1. Once the consent form is completed by the client, staff with permission to use the BVS system on the State of Washington (SAW) system, will access their database to confirm verification of benefits.
2. Upload the Consent form into the DSHS BVS Google Drive, shred paper documents if a paper copy is received.

Database and Documentation.

1. Print to PDF a copy of the monthly verification and upload in the Childplus Enrollment tab: Attachments, Attachment Type: Income Documentation, Description: SNAP, TANF or SNAP/TANF if receiving both.
2. On the Eligibility Verification Form (ERSEA 3b), complete the SNAP/TANF Grant information with information from the BVS verification.