Form H0926, Sharing Facts About Me and My Case with a Community Partner

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Documents

Effective Date: 10/2024

Instructions

Updated: 10/2024

Purpose

A person may apply for TANF, SNAP, Medicaid, CHIP or MEPD programs with help from community organizations or agencies that provide some type of public assistance, called community partners (CPs).

Form H0926 is required when a client provides information to a CP agency that helps individuals and families apply for or receive, HHSC program benefits and services.

Form H0926 is the authorization of the applicant or client. It acknowledges that the applicant or client is giving information to a CP for the CP’s help applying for HHSC program benefits and services on their behalf. If completed on YourTexasBenefits.com, Form H0926 also authorizes HHSC to release case record information to the CP agency when indicated by the applicant or client.

Procedure

When to Prepare

Texas Works:

An applicant or recipient must sign Form H0926 when help from a CP Navigator is provided.

Refer to the Texas Works Handbook, B-1200, Confidentiality, for more information about confidentiality and releasing information.

Medicaid for the Elderly and People with Disabilities (MEPD):

An applicant or recipient must sign Form H0926 when receiving help from a CP Navigator.

Refer to the Medicaid for the Elderly and People with Disabilities Handbook, B-3000, Applications, and C-3000, When and What Information May Be Disclosed, for more information about confidentiality and releasing information.

Number of Copies

Complete an original only.

Transmittal

Submit Form H0926 online on the HHSC Your Texas Benefits website. The paper version of Form H0926 should not be uploaded to the Your Texas Benefits website.

Form Retention

Form H0926 is retained for seven years from the expiration date of the release. If using a paper version of this form, the community partner must retain a copy for seven years.

Detailed Instructions

Case Name — Provide the name as it appears in the HHSC case record for the applicant or person.

Case No. — Provide the case number as it appears in the HHSC case record for the applicant or person. TIERS case numbers are 10 digits.

Applicant First Name — Provide the applicant's first name.

Applicant Last Name — Provide the applicant's last name.

Applicant Date of Birth — Provide the applicant's date of birth.

By signing this form, I understand — Provide the name of the Community Partner Agency.

Name of person submitting form — Provide the name of the person submitting the form.

Case Name — Provide the name of the case.

Community Partner Agency, if any — Provide the CP name.

Address — Enter the street address of community partner agency.

City, State, ZIP Code — Enter the city, state and ZIP Code of community partner agency.

Area Code and Phone No.  — Enter the area code and phone number of community partner agency.

Select one of the following:

  • I am only sharing my personal information to complete my application or make changes to my benefits case: Check this box if the client or applicant is only sharing their personal information with the CP helping them apply for or manage their benefits.
  • Share information about my case including case number(s), benefit program(s), case member name(s), benefit amount, active or inactive, benefit status, start date and renewal date available through Level 3 Community Partner Your Texas Benefits inquiry. This option is not available on the paper version. — Check this box if the client or applicant wants to share their case information through the YourTexasBenefits.com CP search tool.
  • Share my whole case record. This option is not available on the paper version. — Check this box if there are no restrictions on the type of information HHSC can release.
  • Share only the following facts from my case record. This option is not available on the paper version. — Check this box if the client or applicant wants to limit the release of information to specific items or only for a specific period. Enter the type of information such as type or amount of benefits, amount of income or degree of disability.

If applicable, enter the period covered for specific information to be released such as income for August 2024, or information pertinent to the September certification.

This agreement ends on — Enter an expiration date or an expiration event about the person and when they want permission to share information to stop. If no expiration date is entered, permission ends one year from the date signed.

Signature — Provide a physical signature.

The form must be signed by one of the following:

  • Head of the household or certified spouse
  • Client or authorized representative (AR)

Date — Enter the date the form is signed.