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Effective Date: 
12/2013

Documents

Instructions

Updated: 12/2013

PURPOSE

Part I — Veteran Status
To determine if the applicant is a veteran of the U.S. Armed Forces.

 Part II — Medical Information Release

  • To serve as an authorization to release medical information HHSC has about an applicant.
  • To authorize HHSC to release medical information about an applicant to any federal or state agency or department to which the applicant has applied for aid or services.
  • To release HHSC, and the physician, hospital or institution from all legal responsibility and liability that may arise from release of information.

PROCEDURE

When to Prepare

Complete Form H3035 to obtain the applicant’s authorization to get medical information from an optometrist, physician, hospital, institution or other source, or to release information to other agencies.

In response to requests for copies of medical information from other agencies, release the information only if a properly executed Form H3035 or other appropriate release signed by the applicant is on file.

Transmittal

Send an original Form H3035 with each request for medical information.

After the requested medical information is returned, send the original Form H3035 and related medical information to Midland for imaging.

DETAILED INSTRUCTIONS

Mail Code — Enter the office mail code of the local office to which the case is assigned.

HHSC Staff — Enter the name of the staff person.

FAX No. — Enter the staff person's fax number.

Date — Enter the date Form H3035 was signed by the applicant/representative.

Applicant Name — Enter the name of the applicant for Medicaid benefits.

Date of Birth — Enter the applicant's date of birth.

Social Security No. — Enter the patient's Social Security number.

Application/Case No. — If a case number has not been assigned, enter the application number.

PART I — Veteran Status

Check the box — Self-explanatory.

PART II — Medical Information Release

SECTION I – Completed by HHSC

Applicant’s Name — Self-explanatory

DOB — Enter applicant’s date of birth.

List of patient's disabilities — Enter all medical/mental conditions as told to eligibility specialist by the applicant. Remind the applicant that all medical conditions that cause him or her to be disabled should be listed in order to allow the doctor to release information on all impairments.

SECTION II – Completed by applicant or applicant’s authorized representative

Applicant’s Name — Self-explanatory.

Authorization Release — Check all the boxes that apply and enter the name of the doctor, medical facilities or other health providers on the appropriate lines.

This authorization expires on — Enter an expiration date or an expiration event that relates to the individual.

Signature — Applicant or authorized representative's signature.

The applicant must sign all Forms H3035 except if the applicant

  • has been adjudged mentally incompetent and a legal guardian has been appointed. The guardian must sign for the applicant.
  • is 18 years old or older, has been adjudged mentally incompetent, does not have a legal guardian and has not had a judicial restoration of his legal rights. The county judge must sign for the applicant.
  • is an unemancipated minor. The parent or managing conservator must sign, unless someone else is authorized to consent under Chapter 35 of the Texas Family Code.

Date — Enter the date the form is signed.

B-3000, Applications, for definitions.

Signatures of Witness — The signatures of one witness is entered, if required.