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Effective Date: 




Updated: 11/2014



To obtain an individual's authorization to release medical information to:

  • the Texas Health and Human Services Commission (HHSC).
  • a provider.



When to Prepare

  • Prepare when a general authorization to release medical information is needed to complete HHSC forms.
  • Examples of forms that may require an authorization for the release of medical information are:
    • Form 3055, Physician's Order (DAHS)
    • Form 3052, Practitioner's Statement of Medical Need

Number of Copies

Prepare copies, as needed (one for the individual, one for the DADS file, one for the provider, and one for each source of information).


HHSC or the provider is responsible for following the standard procedures for sending this form to the appropriate doctors, medical facilities or other health providers.

Form Retention

Retention is the same as required for the entire case record.


Detailed Instructions

The individual (or personal representative) signs to authorize release of medical information to HHSC or a provider.

Individual's Name — Self-explanatory.

Authorization Release — Enter the name of the doctors, medical facilities, or other health providers, and the name of the form.

Release information to — Enter HHSC or list the provider.

This authorization expires — Enter an expiration date or an expiration event that relates to the individual. Staff determine the expiration date. For example, "end of certification period" or "six-months."

Individual or Personal Representative's Signature — The individual or personal representative signs the form.

Date — Enter the date the form is signed.

Individual or Personal Representative's Signature — The personal representative must be legally designated.

Date — Enter the date the form is signed.

Describe Authority — Describe why the representative has the authority to represent the individual.

Witness Signatures and Date — Two witnesses sign and date the form.