CONSUMER DIRECTED PERSONAL ASSISTANCE PROGRAM

CONSENT TO TRANSFER NECESSARY PERSONAL ASSISTANT MEDICAL DOCUMENTATION

• Form is also available in Portable Document Format (PDF)

I, _____________________________________, consent to allow ________________________________,
      (Consumer Directed Personal Assistant Name, Print)                                                      (Old Fiscal Intermediary)

to provide a copy of my health status and immunization records identified in 18 NYCRR section 766.11(c) and

(d) to _____________________________________. These records must be maintained on file with the fiscal
                        (New Fiscal Intermediary)

intermediary pursuant to 10 NYCRR section 505.28(i). This consent will expire one (1) year from the date of

signature, below.

___________________________________________                  _________________________
Signature                                                                                                     Date