Downloading a Form to Your Computer

Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.

  1. Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
  2. Select the folder you want to save the file in and then click "Save."
  3. Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.

    Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.

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Effective Date: 
1/2015

Documents

Instructions

Updated: 4/2003

Purpose

  • To authorize HHSC staff to request information from a collateral source about clients' eligibility.
  • To authorize a collateral source to release to HHSC information about clients' eligibility.

Procedure

When to Prepare

If the client agrees, and verbal authorization is insufficient, HHSC staff completes Form 0003 to obtain eligibility information.

Note: Do not use Form 0003 to request release of personal health information from health care providers.

Number of Copies

Staff obtains the client's signature on an original of the form during the application process or at the time of the periodic review.

Transmittal

Staff sends the form to the person providing information.

Form Retention

There is no retention requirement.

Detailed Instructions

Staff completes the identifying information at the top of the form. The client and spouse must sign the form.