Authorization to Release Information

We are committed to the privacy of your information.

Please read this form carefully.

"*" indicates required fields

By completing this form, you are giving the Maine Department of Health and Human Services (DHHS) Office for Family Independence (OFI) permission to share certain information with Efficiency Maine.

What is the purpose of the disclosure?

To see if my/my household income level qualifies for Efficiency Maine’s Low-Income Initiatives that could bring down my energy costs.

What information will OFI share with Efficiency Maine?

Confirmation of my/my household’s participation in one or more DHHS program that requires a low to moderate income level; and
Confirmation of my full name, home address, and contact information, including email address and/or phone number, where available.

Please check:*

Yes, I want OFI to release and send my name and contact information to Efficiency Maine.

If you are a Personal Representative (parent, guardian) please enter the name and information of the person who receives/received DHHS benefits.

Individual's Name:*

First*

Middle Initial

Last*

(Jr, III, etc.)

Home Address*

Street Address*

Address Line 2

City*

State

ZIP / Postal Code*

Mailing Address if Different

Street Address

Address Line 2

City

State

ZIP / Postal Code

Phone (10 digits with no punctuation)*

Date of Birth*

(MM/DD/YYYY)

Client ID (if Known)

(8 numbers and 1 letter with no spaces)

I understand and agree that:

I am signing this form voluntarily. I have the right to a copy of this form if I request one.
My current or future treatment, payment for services, or benefits from DHHS will not depend on whether I sign this form. I will not lose my DHHS benefits if I decide not to sign below.
“Information” may be in written, spoken and/or electronic format. My signature allows DHHS/OFI to discuss my information with Efficiency Maine, if necessary.
My information will be kept confidential as required by law. If I choose to share my information with others who are not legally required to keep it private, it may no longer be protected by confidentiality laws.
I may revoke (take back) my permission to release my information by filling out the Revocation Form found at http://www.maine.gov/dhhs/privacy/index.shtml and sending it OFI. The Revocation Form is effective only after it is received and does not apply to information that was already shared.
If I take back my permission or refuse to release some or all of my information, I may not qualify for Efficiency Maine’s Low-Income special incentives.
This form expires one year from the "signed date" below unless I indicate an earlier date here:

Earlier Expiration Date

This form permits additional releases until it expires.

Signed Date*

Signature*

Select "Yes" below if this form was completed and signed by the Personal Representative of the individual who receives benefits from DHHS

Yes

If "Yes," include the Personal Representative’s name and authority to sign for that individual.

Personal Representative's full name:*

First

Last

Personal Representative's authority to sign:*

e.g., Parent, Guardian

Please Check