IPHCA Resources

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Health Care Application Consents

CAC Authorization Form: This form is used when applying for Marketplace Coverage.

Medicaid Consent: This is an example of consent to be used when applying for coverage on a state level. You can also use this for SNAP TANF, simply change the info. This example was submitted by Jane Pauley with their approval. Please check with your compliance department first.

FSSA Rights and Responsibilities: If submitting an application electronically (applicant is not physically in front of you) you are required by FSSA to read this to the applicant.

Verbal Consent: for electronic submission (applicant is not physically in front of you) required to be read by FSSA.

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