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Effective Date: 
10/2004

Documents

Instructions

Updated: 1/2005

 

PURPOSE

To serve as the client's authorization for the Texas Health and Human Services Commission (HHSC) to release information from the case record.

 

PROCEDURE

When to Prepare

Access and Intake

Form 1826-D is completed when the case manager receives a request to release information about a client. An alternative to Form 1826-D is written correspondence containing the information listed on Form 1826-D.

Number of Copies

Complete an original only. The form must be signed by one of the following:

  • client or responsible party (Access and Intake), or
  • personal representative (for release of protected health information).

Transmittal

The client completes the form and returns it to HHSC or faxes a copy to the case manager.

File the original or a copy of Form 1826-D in the Miscellaneous/Correspondence section of the case record.

Form Retention

Retain the original or a copy of Form 1826-D for three years from the expiration date of the release.

 

DETAILED INSTRUCTIONS

Section I

Case Name —  Self-explanatory.

Case Number —  Enter case number.

 

Section II

Part A – Release of Information —  Enter the name of the person or the agency.

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

Release only the following information —  Check this box if the client 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 2000" or "information pertinent to the October certification."

Part B – Purpose of Release —  Enter a description of each purpose of the requested use or disclosure. The statement at the "request of the individual" is a sufficient description of purpose when an individual initiates the authorization and does not elect to provide a statement of purpose.

This authorization expires on —  The client may choose an expiration date or an expiration event for the release of information.

Part C – Signature —  For Access and Intake cases, the client or personal representative will sign the form.
 
Exception: If the client or spouse does not sign the form, a personal representative must sign the form before protected health information is released. To authorize the release of protected health information, either the client or the client's personal representative must sign the form.

Date — Enter the date the form is signed.

If you are signing for the client, please describe your authority to act for the client —  Describe why the representative has the authority to represent the client.

Signatures of Witnesses —  If the person requesting the release of case information cannot sign his/her name, two witnesses to his/her mark (X) must sign. Accept one witness signature in circumstances where it is not possible to obtain two witness signatures. Document the reason in the case record.