CONSUMER DIRECTED PERSONAL ASSISTANCE PROGRAM

CONSENT TO TRANSFER CONSUMER SERVICE AUTHORIZATION RECORDS

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

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

to provide a copy of my records maintained pursuant to 18 NYCRR 505.28(i)(1)(iv), including my service authorization records,

to _____________________________________. This consent will expire one (1) year from the date of signature, below.
                        (New Fiscal Intermediary)

___________________________________________                  _________________________
Signature                                                                                                     Date