The ABCDM 228 form is California’s Applicant’s Authorization for Release of Information, a one-page document from the Department of Social Services that lets you give written permission for a third party — a doctor’s office, a former employer, a school, or another agency — to release specific records to your county welfare department. You’ll most often see it during the application or eligibility review process for CalFresh, CalWORKs, or Medi-Cal, when the county needs documentation you can’t produce yourself. The current version, ABCDM 228 (ENG/SP) (3/24), is available on the CDSS forms page or at your local county welfare office.1California Department of Social Services. On-line Forms and Publications A – D
When You’ll Be Asked to Sign One
Your eligibility worker will hand you an ABCDM 228 whenever the county needs records from an outside source and you can’t provide them on your own. Common examples: verifying past wages with a former employer, confirming a medical condition with your provider, or pulling records from another state agency. Without your signed authorization, California law generally prohibits the county from requesting or receiving that information, because public assistance records and related data are confidential under state law.2California Legislative Information. California Code WIC 10850
The form has a second use. If you want someone to act on your behalf with the county — a lawyer, an advocate, a family member, a friend — a signed ABCDM 228 is the written proof that they may inspect and receive copies of non-privileged information in your case file.3County of Orange Social Services Agency. Client Access to Their Case Records This matters if you’re preparing for a state hearing under Welfare and Institutions Code Section 10950 and need your representative to review the file and build the appeal.4California Legislative Information. California Code WIC 10950
What the Form Asks For
The ABCDM 228 is a single page, bilingual in English and Spanish. It has no case number field, no hearing request section, and no space to explain a dispute. It exists strictly to authorize a release of records. You’ll be asked for the following:5California Department of Social Services. ABCDM 228 – Applicants Authorization for Release of Information
- The name of the agency, institution, or individual holding the records you’re authorizing for release (the “To” line).
- Your full legal name and current address.
- The name of the entity that will receive the records — usually your county welfare department.
- A description of the specific information being requested.
- The purpose of the release, such as “CalFresh eligibility determination.”
- Your birthplace, birthdate, and mother’s maiden name, so the records holder can confirm your identity.
- Your signature and the date.
- Spouse information and signature, if the records involve your spouse.
How to Fill It Out
Start at the “To” line and be precise. A vague entry like “my old job” won’t get results. Write the full name and city of the records holder: “Valley Medical Center, San Jose, CA” or “Target Corporation, Human Resources.” The person receiving this form needs to know exactly who you’re directing to hand over records.
Print your full legal name and current street address on the next line. Then fill in the name of the agency that will receive the released records. In most cases that’s your county department of social services — for example, “Los Angeles County Department of Public Social Services.” If you’re not sure of the exact name, ask your eligibility worker.
The specific-information line is where people tend to get stuck. Be concrete. Instead of “my information,” write something like “employment dates and earnings from January 2025 through December 2025” or “immunization records for Maria Gonzalez, DOB 03/15/2019.” The more specific you are, the faster the records holder can respond.
For the purpose line, a short plain statement works: “verification of income for CalFresh application,” for instance. Your eligibility worker may give you exact language to use. Then complete your birthplace, birthdate, and mother’s maiden name, sign, and date. The form carries a printed acknowledgment that you read it, or had it read to you, before signing; your signature covers that.5California Department of Social Services. ABCDM 228 – Applicants Authorization for Release of Information
If the records involve your spouse, have them complete and sign the spouse section at the bottom. If the records are yours alone, leave that section blank.
Where to Submit It
In most situations, you give the signed form directly to your county welfare office — in person to your eligibility worker or by mail. The county then either forwards it to the records holder or keeps it on file as proof of your authorization when it makes the request.
If you’re using the form to authorize a representative to access your case file, give the signed original to that representative. They’ll present it at the county office when they ask to inspect your records, and they can act on your behalf and review non-privileged information whether or not you’re physically there.3County of Orange Social Services Agency. Client Access to Their Case Records
Keep a copy — a photocopy or a phone photo — before you hand it over. If there’s ever a question about what you authorized, your copy is the proof.
How Long the Authorization Lasts
A signed ABCDM 228 is valid for one year from the date you sign it, unless you write in a shorter expiration or revoke it sooner. One exception: if you have a pending appeal or state hearing, the authorization automatically stays in effect until the hearing reaches a final decision, or until a court resolves the matter if it goes that far.6California Department of Social Services. Confidentiality, Fraud, Civil Rights, and State Hearings
You can revoke the authorization at any time by notifying your county welfare office in writing. Once revoked, the county and the records holder should stop relying on that form. If your circumstances change — a new representative, a move to a different county, a records holder you no longer want involved — send in a written revocation and, if needed, sign a fresh ABCDM 228 naming the updated parties.
The form isn’t a blanket waiver of your privacy. It authorizes release of specific information, for a stated purpose, to a named entity, and the county cannot use it to share your records outside those bounds. Certain records, such as privileged attorney-client communications and the identity of a confidential informant, stay off-limits even with a signed form.7California Department of Social Services. ACIN I-97-10
Faster Alternatives When There’s No Time for Paperwork
If you need to authorize a release quickly and can’t get a signed form to the county in time, California policy lets county offices accept a telephone authorization as a temporary substitute. You call your eligibility worker, identify yourself with items like your case number or Social Security number, and verbally authorize the release. The county will expect a signed written authorization to follow. This comes up often when a medical office or legal aid organization needs immediate access and there’s no time to process paperwork first.6California Department of Social Services. Confidentiality, Fraud, Civil Rights, and State Hearings
There’s also a shortcut that skips the written form entirely. If you and your representative show up at the county office together, no written authorization is required for that visit. The county can release information on the spot. It only covers that one occasion, though. For ongoing access, a signed ABCDM 228 or equivalent written authorization is still necessary.6California Department of Social Services. Confidentiality, Fraud, Civil Rights, and State Hearings
Forms People Confuse It With
The ABCDM 228 is not the form you use to request a state hearing, and it’s not the form you use to designate a representative for that hearing. If you want to appeal a county decision about your benefits, you file a hearing request with the State Hearings Division separately.8California Department of Social Services. State Hearings If you specifically need someone to represent you at a hearing, the DPA 19 is the authorized-representative form built for that.
CDSS also publishes the ABCDM 229, which authorizes release of your information to a community-based organization through the BenefitsCal online portal.1California Department of Social Services. On-line Forms and Publications A – D If a nonprofit or advocacy group is helping you through BenefitsCal, the 229 is the right form, not the 228.