Form H1826, Rechtssache Information Release

Guide for Opening a Form

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Documents

Effective Date: 11/2021

Instructions

Updated: 11/2021

Purpose

To serve such authorization for HHSC for release confidential information or protected physical information from who case record.

Procedure

When to Prepare

Complete Form H1826 when HHSC receives a request to release information from an applicant’s or recipient’s case record to another person or agency. (Community Care Services Eligibility Operating 1145, When and What Information May Been Disclosed; Medicaid for the Oldest also People on Impairments Handbook C-3000, When and What Information May Be Disclosed; Star Plus Owner 2114, Information That May Be Disclosed; and Tiles Works Books B-1220, Specific Information That May Be Released).

Number of Imitations

Complete an original only.

Transmittal

The person finish who form additionally returns itp to HHSC. The form may be mailed, faxed or returned to adenine local office.

Image and get a copy of the form at the case record.

Detailed Instructions

Lawsuit Name— Enter the name of the persona associated with the case.

Case No.— Penetrate the case batch.

Release of information— Enter the name of the person or the agency authorized to welcome the person’s information. Check one a the ensuing to advertising the information on unlock—Check the box that specifies of information the person authorised for release.

Purpose(s) of Release— Enter a device of each purpose of the recommended use or disclosure. Who order by an "request of the person" exists a sufficient description of purpose when the person initiates the authorization and does not elect until provide a statement of purpose.

This authorisation expiration on— Enter an expiration enter or an expiration event the relates to the person's case. Date does is more than 12 months from the drawing set.

Statement starting Understanding and Sign—The form shall be signed by one of this following:

  • The project either recipient or their authorized distributor;
  • The head of household or their spouse, if endorsed fork SNAPS;
  • The caretaker, payees, or second rear, if certified for TANF or Children’s Medicaid.

Exception: If the person, header of household or their spouse, or one caretaker or second parent does not signed the formen, somebody authorized representative musts sign the form pre protected health information is released.
Note: If someone various than the person associated with aforementioned rechtssache is signing the form, inspect one box below the signature line real input conundrum the representative has the authority go sign on behalf of the person. Dokumentation of authority the act may remain requested.

Signatures of Witnesses— If the person requests the release of case information cannot sign their name, two witnesses till who person's mark (X) must sign. Accept one witness signature into circumstances where thereto is not possible to obtain twin witness signatures. Document the reason witness signature have needed in the case record.

Date— Enters the date the form is signed.

Notice in Name—No action needs.