Effective Date: 
9/2004

Documents

Instructions

Updated: 2/2006

PURPOSE

To serve as the client's authorization for HHSC to release information from the case record.

PROCEDURE

When to Prepare

Texas Works:

Form H1826 is completed when the certification office receives a request to release information about a client, for reasons listed in B-1200 in the Policy and Procedures Section. An alternative to Form H1826 is written correspondence containing the information listed in B-1200.

Long Term Care (LTC):

Form H1826 is completed when the eligibility specialist receives a request to release information about a client. Refer to Section 1600 of the Medicaid Eligibility Handbook,Section 1600 of the In-Home and Family Support Program Handbook, Item 1140 of the Community Care for Aged and Disabled Handbook, and Section 1800 of the Case Manager Community Based Alternatives Handbook for department policy on release of information. An alternative to Form H1826 is written correspondence containing the information listed on Form H1826.

Number of Copies

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

  • the caretaker/payee or second parent (TANF/Medical Programs)
  • head of the household or certified spouse (Food Stamps)
  • client or responsible party (LTC)
  • 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 advisor.

File the original or a copy of Form H1826 in the Miscellaneous/Correspondence section of the case record.

Form Retention

Retain the original or a copy of Form H1826 for six years from the expiration date of the release.

DETAILED INSTRUCTIONS

Case Name— Self-explanatory.

Case Number— Enter case number.

I authorize release of information to— Enter the name of the person or the agency.

General Request— Check this box if there are no restrictions on the type of information to be released.

Specific Request— 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," "information pertinent to the October certification."

Purpose of Request— 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— An expiration date or an expiration event that relates to the individual.

Signature— For food stamp cases, the head of the household or spouse, if certified for benefits, signs the form. For TANF/Medicaid cases, the caretaker/payee or second parent signs. For LTC, client or responsible party.

Exception: If the client, head of household/spouse, or caretaker/second parent does not sign the form, a "personal representative" must sign the form before protected health information is released.

Date— Enter the date the form is signed.

Personal Representative Authority— Describe why the representative has the authority to represent the client. Refer to handbook Item B-1212 (TW), Item 1634 (MEH), Item 1634 (IH/FSP), Item 1150 (CCAD), and Item 1819 (CM-CBA) for definitions.

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.

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