February 21, 2019

Anyljawan Fields
109 Waters Circle
Apartment 93
Midland City, AL 36350

Dear Anyljawan:

You were referred to me to assist you with understanding how your Social Security Disability
Insurance or Supplemental Income and health insurance will be affected when you go to work.

To begin this process, I will need you to sign and date all three of the "Release of
Information" forms I have included in this packet and mail them back to me using the self-
addressed envelope Ihave included. Ihave highlightedthe forms in yellow where you need
to sign and date.

Iappreciate your cooperation and look forward to speaking with you very soon.

Sincerely,

l<ntetk<i'D<vi&

Talethia Dark, CWIC

Benefits Counselor
560 S. Lawrence Street
Montgomery, AL 36104
334-293-7274
1-877-816-4602 toll free
334-293-7392 fax

Td/kt
 WORK INCENTIVES PLANNING AND ASSISTANCE PROJECT
OF THE
ALABAMA DEPARTMENT OF REHABILITATION SERVICES

AUTHORIZATION FOR USE, DISCLOSURE AND/OR RELEASE OF INFORMATION

Client Name: Anyljawan Fields

Client Address: 109 Waters Circle Apartment 93 Midland City, AL 36350
Date ofBirth: 1/2/2000 Social Security Number: 418-51-1113
Parent/Guardian/Surrogate Parent Name:

I give my permission for the following individual or agency to obtain, release and/or discuss the protected information
checked below about me in establishing and determining specifics necessary for use in work incentives planning and
assistance.

I understand this information will be private and that my permission is voluntary

Iunderstand at any time, Ican revoke this permission by notifying Talethia Dark in writing
I understand a revocation will not be retroactive and will not affect disclosures prior to revocation
I understand the information to be released may contain information about any of the conditions/documents below
I understand this information may include sensitive material and I authorize release for the purpose stated
I understand information used or disclosed related to this authorization may be subject to redlsclosure by the recipient for the purpose of work
incentive planning and assistance and may no longer be protected by federal or state law
I understand my right to request WIPA/ADRS to restrict the release of the requested information
I understand this information is being obtained for purposes of eligibilitydetermination and/or planning and completing a benefits summary and
analysis and work incentives plan

The individual and/or agency allowed to release and discuss this information:
Name: APRS
Address: 560 South Lawrence Street City: Montgomery State: AL Zip Code: 36104
Telephone: (334) 293-7146 or 1-877-816-4602 Fax: (334) 293-7392

The information should be released to or discussed with:

Name: Talethia Dark, CWIC

Address: 560 South Lawrence Street City: Montgomery State: AL Zip Code: 36104
Telephone: (334) 293-7146 or 1-877-816-4602 Fax: (334)293-7392

The following written, verbal, audio/video or electronic information may be released:

Health and/or Medical Records
High School/College Transcripts
Other School Records/Reports
Mental Health Treatment Repts
<J Progress Notes and Reports
Dental Records
Staffing Reports Discharge Summary
Vision/Hearing Reports Psychiatric Records
Psych Test and Records Therapy/Test Rep (OT, PT, ST)
Drug and/or Alcohol Rec/Rep J Other General info; BS&A
Employment/Personnel Records
J Individ Plan for Employ (IPE)

I understand I have the right to refuse to sign this authorization. My refusal to release certain information
may affect my eligibility and/or services for this assistance.

(Slant Signature/Representative/Guardian/Parent Witness Signature

One year following signature date

Date Expiration Date
Note: ADRS/W1PA cannot pay for records Photocopies of this release form wBIbe considered as an original.
Sent by-XT Kathy Tyner
Social Security Administration Form Approved
Consent for Release of Information omb No. 0960-0566
You must complete all required fields. We will not honor your request unless all required fields are completed.
('signifies a required field).
TO: Social Security Administration

Anyljawan Fields 1/2/2000 418-51-1113

*My Full Name *My Date of Birth *My Social Security Number
(MM/DD/YYYY)
I authorize the Social Security Administration to release information or records about me to:
'NAME OF PERSON OR ORGANIZATION: 'ADDRESS OF PERSON OR ORGANIZATION:
Talethia Dark, CWiC FAX: (334) 293-7392
Alabama Department of Rehabilitation Services 560 South Lawrence Street
Benefits Counseling Program Montgomery AL 36104

*l want this information released because: I am planning to go to work and need this information for benefits and work
We may charge a fee to release information for non-program purposes.
incentives planning. Please send a Benefits Planning Query (BPQY).

'Please release the following information selected from the list below:
You must specify the records you are requesting by checking at least one box. We will not honor a request for "any and all
records" or "my entire file." Also, we will not disclose records unless you include the applicable date ranges where requested.

1. • Social Security Number

2. [x] Current monthly Social Security benefit amount
3. [x] Current monthly Supplemental Security Income payment amount
4. • My benefit or paymentamounts from date to date
5. • My Medicare entitlement from date to date
6. • Medical recordsfrom myclaims folder(s) from date to date
Ifyou want us to release a minor child's medical records, do not use this form. Instead, contact your local Social
Security office.
7. • Complete medical records from my claims folder(s)
8. [x] Otherrecord(s) from myfile (you must specify the records you are requesting, e.g., doctor report, application,
determination or questionnaire)
My cash benefits, health insurance information, medical review dates, representation, SSDI and SSI work activity and earnings.
All employment supports data on my SSA record.

I am the individual, to whom the requested information or record applies, or the parent or legal guardian of a minor, or
the legal guardian of a legally incompetent adult. I declare under penalty of perjury (28 CFR § 16.41(d)(2004)) that I have
examined all the information on this form, and any accompanying statements or forms, and it is true and correct to the
best of my knowledge. I understand that anyone who knowingly or willfully seeks or obtain access to records about
another person under false pretenses is punishable by a fine of up to $5,000. I also understand that I must pay all
applicable fees for requesting information for a non-program-related purpose.
'Signature: 'Date:
'Address: 109 Waters Circle Apartment 93 Midland City, AL 36350
Relationship (if not the subject of the record): 'Daytime Phone
Witnesses must sign this form ONLY if the above signature is by mark (X). Ifsigned by mark (X), two witnesses to the signing
who know the signee must sign below and provide their full addresses. Please print the signee's name next to the mark (X)on the
signature line above.
1.Signature of witness 2.Signature of witness

Address(Number and streeLCity.State, and Zip Code) Address(Number and streeLCity.State, and Zip Code)

Form SSA-3288 (07-2013) EF (07-2013)

Social Security Administration Form Approved
Consent for Release of Information OMB No. 0960-0566
You must complete all required fields. We will not honor your request unless all required fields are completed, ('signifies a
required field).
TO: Social Security Administration

Anyljawan Fields 1/2/2000 418-51-1113

'My Full Name 'My Date of Birth 'My Social Security Number
(MM/DD/YYYY)
I authorize the Social Security Administration to release information or records about me to:
'NAME OF PERSON OR ORGANIZATION: 'ADDRESS OF PERSON OR ORGANIZATION:
Talethia Dark, CWIC FAX: (334) 293-7392
Alabama Department of Rehabilitation Services 560 South Lawrence Street
Benefits Counseling Program Montgomery AL 36104

*l want this information released because: I am planning to go to work and need this information for benefits and work
We may charge a fee to release information for non-program purposes.
incentives planning. Please send a Benefits Planning Query (BPQY).

'Please release the following information selected from the list below:
You must specify the records you are requesting by checking at least one box. We will not honor a request for "any and all
records" or "my entire file." Also, we will not disclose records unless you include the applicable date ranges where requested.

1. Q SocialSecurity Number
2. D Current monthly Social Security benefit amount
3. • Currentmonthly Supplemental Security Income payment amount
4. • My benefit or payment amounts from date to date
5. • My Medicare entitlement from date to date
6. • Medical records from my claimsfolder(s) from date to date
Ifyou want us to release a minor child's medical records, do not use this form. Instead, contact your local Social
Security office.
7. Q Complete medical recordsfrom my claims folder(s)
8. (x] Other record(s) from my file (you must specify the records you are requesting, e.g., doctor report, application,
determination or questionnaire)
Non-certified yearly totals of earnings.

I am the individual, to whom the requested information or record applies, or the parent or legal guardian of a minor, or
the legal guardian of a legally incompetent adult I declare under penalty of perjury (28 CFR § 16.41(d)(2004)) that I have
examined all the information on this form, and any accompanying statements or forms, and it is true and correct to the
best of my knowledge. I understand that anyone who knowingly or willfully seeks or obtain access to records about
another person under false pretenses is punishable by a fine of up to $5,000. I also understand that I must pay all
applicable fees for requesting information for a non-program-related purpose.
'Signature: 'Date:
'Address: 109Waters Circle Apartment93 Midland City, AL 36350

Relationship (if not the subject of the record): 'Daytime Phone:

Witnesses must sign this form ONLY if the above signature is by mark (X). If signed by mark (X), two witnesses to the signing
who know the signee must sign below and provide their full addresses. Please print the signee's name next to the mark (X) on the
signature line above.

1.Signature of witness 2.Signature of witness

Address(Number and street.City.State, and Zip Code) Address(Number and street.City.State, and Zip Code)

Form SSA-3288 (07-2013) EF (07-2013)