Form Dphhs Qad Crl 18 PDF Details

Dphhs Qad Crl 18 is a document that is used to request or receive services from the Department of Public Health and Human Services. This document can be used for a variety of purposes, including but not limited to: requesting food stamps, Medicaid, or Child Protective Services. The form can be completed by the individual applying for assistance or by their representative. Dphhs Qad Crl 18 must be filled out completely and accurately in order to ensure that you receive the correct services from the Department of Public Health and Human Services. If you are in need of assistance from the Department of Public Health and Human Services, Dphhs Qad Crl 18 is the form you will need to fill out. This document can be used for a variety of purposes, so make sure to complete it fully and accurately. With this form, you can request food stamps, Medicaid, or Child Protective Services depending on your needs. Contact the Department of Public Health and Human Services today if you have any quest

QuestionAnswer
Form NameForm Dphhs Qad Crl 18
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescrl018 dphhs release of information

Form Preview Example

DPHHS-QAD/CRL-18 (Revision 3-10)

DEPARTMENT OF

PUBLIC HEALTH AND HUMAN SERVICES

STATE OF MONTANA

- RELEASE OF INFORMATION -

For Adult and Youth Care Facility Providers

Criminal / Protective Service / Motor Vehicle

Background Checks

PERSONAL INFORMATION

Section A – Current Information

Phone # ________________________

Legal Name: ______________________________________________________________________________________

(First)(Middle)(Maiden)(Last)

Aliases/Other Names Used: __________________________________________________________________________

Residential Address: ________________________________________________________________________________

(Street)(City) (State ) (Zip)

Mailing Address: ___________________________________________________________________________________

 

 

 

 

 

 

(Street)

 

 

(City)

(State )

(Zip)

 

 

Sex: [

] Male

[ ] Female

Date of Birth: _________________

Social Security #_________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section B – Past Residences

 

 

 

 

 

 

 

 

 

 

 

 

Within the last five (5) years, have you…

 

 

 

 

 

 

 

 

1.

…lived in another state?

 

 

 

 

[

] Yes

[

] No

 

 

2.

…lived on or do you now live in an area designated as an Indian reservation?

[

] Yes

[

] No

 

 

 

If you answered yes to the any of the above questions:

 

 

 

 

 

 

 

 

 

 

Please state where you have lived since turning 18 in the table below.

 

 

 

 

 

 

 

 

You will need to obtain an out of state background check or a tribal background check at your cost.

 

 

 

 

City

 

 

 

County

 

Reservation

State

Dates of Residency (From – To)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section D – Employment Status

The facility that I am working / living at is:

Director Name / Facility Name: ___________________________________________________________________

Facility Mailing Address: ________________________________________________________________________

PLEASE COMPLETE BOTH SIDES OF THIS FORM

Section E – Authorization Statement and Signature

I, ____________________ (applicant name), am aware that __________________________________ (provider or its

authorized representative), has requested confidential information from the Montana Department of Public Health and Human Services, in accordance with 41-3-205(3)(o), MCA as part of a review of my personal background in connection with my status as a current or prospective employee of or volunteer for that entity.

I am aware that CFSD, DMV, and DOJ records may contain information that could adversely affect my employment or volunteer status and/or approval as outlined in ARM 37.95.161 and ARM 37.95.176. These records will relate to any substantiated report(s) of child abuse or neglect in Montana, criminal history records, and motor vehicle records. As a household member, I understand that I am also subject to the above requirements.

I am also aware that although the entities or individuals requesting and receiving confidential CFSD information are bound by law or agreement with DPHHS to protect or preserve its confidential nature, DPHHS has no ability or authority to ensure that confidentiality is maintained after this information is released by DPHHS.

In full acknowledgement of the above information and notice, I authorize CFSD to provide the requested confidential information to__________________________________________ (provider or its authorized representative), and I

hereby also release CFSD from any claims or causes of action which may subsequently arise from release of this confidential information.

NOTE: Any deletions or oversights may result in the denial of your application.

Signed: _______________________________________________________________ Date: ____________________

(To be signed in front of a notary)

TO BE COMPLETED BY A NOTARY PUBLIC:

Taken, sworn, and subscribed before me this ____________ day of _________________________ A.D. ____________

_________________________________________________________

Notary Public for the State of Montana

Residing at: _______________________________________________

My commission expires: _____________________________________

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This form will involve specific details; in order to ensure consistency, you need to take note of the next suggestions:

1. You need to fill out the Form Dphhs Qad Crl 18 properly, thus be careful while working with the segments that contain all of these blanks:

Stage number 1 of filling out Form Dphhs Qad Crl 18

2. Once the last section is completed, go to type in the suitable details in all these - Dates of Residency From To, Section D Employment Status The, Director Name Facility Name, Facility Mailing Address, and PLEASE COMPLETE BOTH SIDES OF THIS.

Dates of Residency From  To, Director Name  Facility Name, and Section D  Employment Status The of Form Dphhs Qad Crl 18

3. Completing Section E Authorization Statement, I am aware that CFSD DMV and DOJ, I am also aware that although the, and In full acknowledgement of the is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Part number 3 for completing Form Dphhs Qad Crl 18

4. All set to complete this fourth form section! In this case you'll have all of these Signed Date, To be signed in front of a notary, TO BE COMPLETED BY A NOTARY PUBLIC, Taken sworn and subscribed before, Notary Public for the State of, Residing at, and My commission expires form blanks to fill out.

Part # 4 in submitting Form Dphhs Qad Crl 18

As for TO BE COMPLETED BY A NOTARY PUBLIC and My commission expires, make sure you double-check them in this section. These two could be the most important ones in this form.

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