Required Fields

Salutation
-- Mr. Mrs. Ms. Miss Mr. and Mrs. Dr. Prof. Senator Gov. Congressman Hon. Fr. Sister Rabbi Reverend Admiral Commander Colonel General Lieutenant Lt. Col. LCDR Major Private Sergeant Petty Officer

First Name

Middle Name / Initial

Last Name

Street Address

Street Address (2)

City

State
-- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

County

Zip Code

e-mail

Verify e-mail

Daytime Phone

Evening Phone

Mobile Phone

Please describe your problem/inquiry and how you would like the senator to help.

Type of assistance for which applied (food stamps, Medicaid, TANF, etc.)

Application Date

Case Number

Date of Birth

 I hereby authorize the named legislator and his/her legislative staff members to make inquiries and to receive confidential information from the proper officials regarding my concern. I understand that such inquiries may involve the disclosure of confidential information, including but not limited to health information otherwise protected as confidential under the Health Information Portability and Accountability Act (HIPAA). I authorize only the release of information directly relevant to my inquiry. This authorization shall automatically expire within sixty (60) days of date of the form, unless written notice of revocation is received by the legislator's office prior to that date.  

If you would prefer to submit this form via fax, please print and complete the Information Privacy Authorization Form and fax it to 317-234-9226.

I do not authorize the release of confidential information at this time.