DSS Data Sharing Consent Form

Overview Data sharing between DSS and other state agencies and partner organizations helps DSS clients obtain the full range of benefits for which they are eligible. People who participate in DSS programs are often eligible for other services and benefits. By sharing a limited amount of data about you and your enrollment in DSS programs, DSS can help connect you to valuable services and streamline enrollment into those services. However, we understand you may not want DSS to share your data for these purposes. If you don’t want your data to be shared, you can opt out through this website and we won’t share your information to help you get other services or benefits. Important Considerations Before Opting Out At DSS, we value your personal data and make it a priority to safeguard it. One of the only reasons we share your data is to identify other services or benefits that you may be eligible for, or to verify your eligibility for such services or benefits. DSS may share this information with:

1. State government agencies such as:
- a. the Department of Public Health (DPH) to see if you are eligible for the Women, Infants and Children (WIC) program;
- b. the Office of Early Childhood (OEC) to see if you are eligible for childcare assistance; or
- c. the Department of Revenue Services (DRS) to see if you are eligible for tax credits;
2. Utility companies to see if you are eligible for hardship status or discount rates; and
3. Non-profit organizations partnering with the state to offer services, such as SimplifyCT for the purpose of providing free tax preparation assistance.

DSS only shares the minimum amount of information needed to identify services or benefits you may be eligible for, or to verify your eligibility for such services or benefits. While entities that receive information from DSS may not be covered by certain federal confidentiality laws, DSS will only disclose the minimum amount of information needed to identify services or benefits that you may be eligible for or to verify your eligibility for such services or benefits. DSS also prohibits these entities from redisclosing, selling, or using your information for any other purpose. Choosing to share or not share your information will not have any effect on your DSS benefits. DSS will not share your information with US Citizenship and Immigration Services as part of this data sharing. How you can use this website Through this website, you can:

1. Opt-out of DSS sharing your data for the above purposes. If you choose to opt out, it will not affect your eligibility for any DSS program or benefit.
2. Opt-in to allow DSS to share your data for the above purposes. If you have previously completed an opt-out request through this website.

Note: * indicates required fields.

Basic Information

First Name*

Middle Name

Last Name *

Suffix

SSN or DSS Client ID is required*

SSN

(OR)

DSS Client ID

DOB*

(MM/DD/YYYY)

Choose the action *

Opt-out: I do not want DSS to share my data for the above listed purposes.

Opt-in: I chose to opt out before but now I want DSS to share my data for the above listed purposes.

Action is required.