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Public Record Request FormHW 0331 09/19 Records Request Form Available in Spanish. We provide interpreter services at no cost. Call 2-1-1 or 1-800-926-2588 for interpretation assistance. Disponible en espanol. Proveemos servicios de intérprete sin costo alguno. Llame al 2-1-1 ó al 1-800-926-2588 para obtener la ayuda de un intérprete. Please provide your contact information in case we have questions regarding your request for information. 1. Requester’s Name (please print)______________________________ Telephone _______________________________ Mailing Address ______________________________________________ Fax Number (optional)_____________________________ City, ST ZIP __________________________________ e-mail address __________________________________________________ If you are requesting records about a specific individual, please include the individual’s information. Individual’s Name ______________________________________________ Individual’s Date of Birth ____________________ (First, MI, Last) Individual’s Address ____________________________________________ Individual’s Telephone ______________________ City, ST ZIP __________________________________________________ 2. Detailed Description of Records Requested - Please be very specific. For example, including case number, time frame of records requested, or the name of the benefit or service involved may help expedite the request. ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ 4. Requester’s Signature ________________________________________ Date requested ____________________________ If you are requesting individual-specific information, including yours, your signature must be notarized. I, _________________________________________ being a Notary Public, do hereby certify that on this day _________ of ______________________, 20_____, the above individual, having been first duly sworn, appeared before me and signed the foregoing document. _______________________________________________ S E A L Signature of Notary Public Notary Public residing at ____________________________ My commission expires on ________________________ 5. If this request is being made by someone other than the subject of the record, it must be accompanied by either a notarized Authorization for Disclosure form, or verification that the requester is an attorney seeking records about a client. Send Completed Form by one of the following methods: email: PRR@dhw.idaho.gov; fax: 208/639-5742 Or mail to: Department of Health and Welfare, Public Records Request, P. O. Box 83720, Boise, Idaho 83720-0036 For questions call: 208/334-5564 For DHW Office use only ● ID Provided _________ ● Form Complete_______ Authority ● Accessing own records_____ ● Documentation Attached _____ ● Not Required ________ 3. Do you want to: ___Examine the requested records; or ___Receive a copy of the requested records (fee(s) may be charged). Do you want the response sent by: _____ email ____ mail _____ fax The Department will notify you in writing as soon as possible if your request cannot be responded to within three working days. If a fee will be charged, the Department will notify you in writing of the estimated cost and may require prepayment.