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Effective Date: 
3/2019

Documents

 

Instructions

Updated: 3/2019

 

Purpose

A person may apply for TANF, SNAP, Medicaid, CHIP or MEPD programs with assistance from community organizations or agencies that provide some type of public assistance, which are called community partners (CPs).

Form H0926 is required when a client is providing information to a CP agency that provides assistance to individuals and families that are applying for, or are receiving, HHSC program benefits and services.

Form H0926 is the authorization of the applicant or client acknowledging that they are providing information to a CP for the CP's assistance on their behalf for the purpose of applying for HHSC program benefits and services. Form H0926 also authorizes HHSC to release case record information to the CP agency when indicated by applicant/client.

 

Procedure

When to Prepare

Texas Works:

An applicant or recipient must sign Form H0926 when assistance from a CP Navigator is provided.

Refer to the Texas Works Handbook, B-1200, Confidentiality, for more information about confidentiality and releasing information.

Medicaid for the Elderly and People with Disabilities (MEPD):

An applicant or recipient must sign Form H0926 when receiving assistance from a CP Navigator.

Refer to the Medicaid for the Elderly and People with Disabilities Handbook, B-3000, Applications, and C-3000, When and What Information May Be Disclosed, for more information about confidentiality and releasing information.

Number of Copies

Complete an original only.

Transmittal

Form H0926 should be submitted online within the HHSC Your Texas Benefits website.

Form Retention

Form H0926 is retained for seven years from the expiration date of the release.

 

Detailed Instructions

Case Name — Provide the name as it appears in the HHSC case record for the applicant or an individual.

Case No. — Provide the case number as it appears in the HHSC case record for the applicant or individual. TIERS case numbers are 10 digits.

Applicant First Name — Provide the applicant's first name.

Applicant Last Name — Provide the applicant's last name.

Applicant Date of Birth — Provide the applicant's date of birth.

By signing this form, I understand — Enter the name of the CP agency assisting the applicant.

Case Name — Provide the name of the client/applicant signing and submitting the form. Community Partner Agency (if any) — Provide the CP name.

Address — Enter the street address.

City, State, ZIP Code — Enter the city, state and ZIP Code.

Phone No. and area code — Enter the area code and Phone number.

I am only sharing my personal information to complete my application or make changes to my benefits case: Check this box if the client/applicant is only sharing their personal information with the CP assisting them in applying for or managing their benefits.

Share all of my case record — Check this box if there are no restrictions on the type of information to be released by HHSC.

Share my information through YourTexasBenefits.com inquiry; case number(s), benefit program(s), case member name(s), benefit amount or active/inactive, benefit status, start date and renewal date. — Check this box if the client/applicant wants to share their case information through the YourTexasBenefits.com CP search tool.

Share only the following facts from my case record — Check this box if the client/applicant wants to limit the release of information to specific items or only for a specific time period. Enter the type of information such as "type or amount of benefits," "amount of income" or "degree of disability."

If applicable, enter the period covered for specific information to be released such as "income for September 2011" or "information pertinent to the October certification."

This agreement ends on — Enter an expiration date or an expiration event that relates to the individual when he wants permission to share information to stop. If no expiration date is entered, permission ends one year from the date signed.

My Signature

The form must be signed by one of the following:

  • Head of the household or certified spouse (SNAP only)
  • Client or legally authorized representative (LAR) (TANF/Medical programs/MEPD)

Date — Enter the date the form is signed.

If you are signing as the legally authorized representative . . . — Check the box that describes why the LAR has the authority to represent the individual. (See definition of LAR in Signature Section above). Information about authorized representatives can be found in:

Note: The LAR is defined as:

  • A parent or legal guardian if the person is a minor.
  • A legal guardian if a judge has ruled the person is not competent to manage his or her own personal affairs.
  • An agent named as the person's durable power of attorney for health care.
  • The person's court-appointed attorney ad litem.
  • The person's court-appointed guardian ad litem.
  • A personal representative or statutory beneficiary if the person is deceased.
  • An attorney retained by the person or by another person listed on this form.
  • If the person is deceased, their personal representative must be the executor, independent executor, administrator, independent administrator or temporary administrator of the estate.