Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
To obtain client authorization to release medical information to
- 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.
Retention is the same as required for the entire case record.
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.