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Effective Date: 




Updated: 4/2003



To obtain client authorization to release medical information to

  • HHSC.
  • a provider agency.


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:
    • Physician's Order (DAHS) – 3055
    • Physician's Order (Medicaid Primary Home Care Services) – 3055-A
    • Level-of-Care (LOC) – 3650
    • Client Assessment, Review, and Evaluation (CARE) – 3652-A

Number of Copies

Prepare copies as needed (one for the client, one for the HHSC file, one for the provider agency, and one for each source of information).


HHSC or the provider agency 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 client (or personal representative) signs to authorize release of medical information to HHSC or a provider agency.

Patient's Name — Self-explanatory.

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

Release information to — Enter HHSC or list the provider agency.

This authorization expires on — 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."

Signature — Client or personal representative's signature.

Date — Enter the date the form is signed.

Personal Representative — Must be legally designated.

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

Witness Signatures — The signatures of two witnesses.