1. (a) Each applicant and each adult member of the applicant's household seeking township assistance must consent to a disclosure and release of information about the applicant and the applicant's household before township assistance may be provided by the township trustee. The consent must be made by signing a form prescribed by the state board of accounts. The form must include the following:

   1. (1) The applicant's name, case number, and address.

   2. (2) The types of information being solicited, including the following:

      1. (A) Countable income.
      2. (B) Countable assets.
      3. (C) Wasted resources.
      4. (D) Relatives capable of providing assistance.
      5. (E) Past or present employment.
      6. (F) Pending claims or causes of action.
      7. (G) A medical condition if relevant to work or workfare requirements.
      8. (H) Any other information required by law.
   3. (3) The names of individuals, agencies, and township trustee offices that will receive the information.
   4. (4) The expiration date of the permission to disclose information.
2. (b) Information that is declared to be confidential by state or federal statute may not be obtained under the consent form prescribed by this section.
3. (c) The township trustee shall keep on file and shall make available to the division of family resources and office of Medicaid policy and planning upon request a copy of the signed consent form described in subsection (a).
4. (d) The township trustee shall send to the county office a copy of the signed consent form described in subsection (a).
5. (e) The division of family resources, county offices, and the office of Medicaid policy and planning shall make available to the township trustee upon request a copy of signed consent to disclosure and release of information forms in each entity's files.

6. (f) If an individual who is required to sign a form under this section is unable to sign the form in the township trustee's office due to a physical or mental disability or illness, the township trustee shall make alternate arrangements to obtain the individual's signature.

   [Pre-1992 Revision Citation: 12-2-13-1.]

As added by P.L.2-1992, SEC.14. Amended by P.L.4-1993, SEC.193; P.L.5-1993, SEC.206; P.L.46-1995, SEC.57; P.L.51-1996, SEC.31; P.L.259-2001, SEC.5; P.L.73-2005, SEC.39; P.L.145-2006, SEC.115.