the following type(s) of information form my records (any specific portion thereof):
DEMOGRAPHIC, INCOME, HOUSING AND/OR EMPLOYMENT STATUS
for the purpose of:
ELIGIBILITY DETERMINATION, PROGRAM COMPLIANCE, AND CASE MANAGEMENT
I understand that the federal Privacy Rule ("HIPAA") does not protect the privacy of information if re-disclosed, and therefore request that all information obtained from this person or agency be held strictly confidential and not be further released by the recipient. I further understand that my eligibility for benefits, treatment or payment is not conditioned upon my provision of this authorization. I intend this document to be a valid authorization conforming to all requirements of the Privacy Rule and understand that my authorization will remain in effect for: