Form H0003, Agreement to Release Your Facts

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Effective Date: 8/2015

Updated: 7/2005

To authorize

Health and Human Services Commission (HHSC) staff to request information from a collateral source about client's eligibility.
a collateral source to release to HHSC information about client's eligibility.

If the client agrees, and verbal authorization is insufficient, HHSC staff complete Form H0003 to obtain eligibility information.

Note: Do not use Form H0003 to request release of personal health information from health care providers.

Staff obtain the client's signature on an original of the form during the application process or at the time of the periodic review.

Staff send the form to the person providing information.

There is no retention requirement.

Staff complete the identifying information at the top of the form. The client and spouse must sign the form.