Form H1046, Inpatient Medical Services Certification

Instructions for Opening a Form

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Effective Date
01/2022
h1046.pdf (203.36 KB)
h1046-s.pdf (1.33 MB)

Instructions

Updated: 01/2022

Purpose

To provide Texas Department of Criminal Justice (TDCJ), Texas Juvenile Justice Department (TJJD) and Juvenile Probation Department (JPD) staff a method to notify HHSC when an incarcerated person received inpatient services in a medical institution.

Procedure

When to Prepare

When a person in TDCJ, TJJD or JPD custody received treatment in a medical institution for at least 24 hours.

Number of Copies

Complete an original for each person who received treatment in a medical institution for at least 24 hours.

Transmittal

TDCJ, TJJD or JPD staff submit the completed form, including the practitioner’s signature, to HHSC.

Detailed Instructions

Part I

Contact Information — TDCJ, TJJD or JPD staff complete Part I to provide their contact information and basic patient information to HHSC.

Name of Patient — Enter the patient’s name.

Patient SSN — Enter the patient’s Social Security number.

Patient Date of Birth — Enter the patient’s date of birth.

Name of TDCJ, TJJD or JPD Contact — Enter the name of the contact.

Phone No. of TDCJ, TJJD or JPD Contact — Enter the phone number of the contact.

Part II

Practitioner Information — The practitioner completes Part II to certify that the patient received inpatient medical services for at least 24 hours.

Date Inpatient Treatment Began — Enter the treatment begin date as mm/dd/yyyy.

Date Inpatient Treatment Ended — Enter the treatment end date as mm/dd/yyyy.

Signature – Practitioner — Handwritten signature of practitioner. 

Date — Enter the date the practitioner signed the form as mm/dd/yyyy.

Print Name of Practitioner — Enter the practitioner’s name.

Type of Practice — Enter the practitioner’s type of practice (e.g., MD, DO, DDS).

Phone No. — Enter the practitioner’s phone number.

Mailing Address — Enter the practitioner’s mailing address.

Part III

Patient Information — The patient completes Part III to release their facts.

Name of Patient — Enter the patient’s name.

This approval ends on this date — Enter the date the medical release approval ends.

Patient or representative’s signature — The patient signs to release their medical facts to HHSC.

Date — Enter the date the patient or their representative signed as mm/dd/yyyy.

If you are the patient’s representative, tell us why (by what authority) you can act for the client — Briefly describe the authority that allows the person to function as the patient’s representative.

Witness 1 Signature — If the patient only signs their name as an “X” and does not have a representative, request a witness signature. 

Date — If signed by a witness, enter the date the witness signed the form. 

Witness 2 Signature — If the patient only signs their name as an “X” and does not have a representative, request a witness signature.

Date — If signed by a witness, enter the date the witness signed the form.