Form 0003, Authorization to Furnish Information

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Effective Date: 1/2015

Updated: 4/2003

To authorize HHSC staff to request information from a collateral source about clients' eligibility.
To authorize a collateral source to release to HHSC information about clients' eligibility.

If the client agrees, and verbal authorization is insufficient, HHSC staff completes Form 0003 to obtain eligibility information.

Note: Do not use Form 0003 to request release of personal health information from health care providers.

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

Staff sends the form to the person providing information.

There is no retention requirement.

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