To serve as authorization for HHSC to release confidential information or protected health information from the case record.
When to Prepare
Complete Form H1826 when HHSC receives a request to release information from an applicant’s or recipient’s case record to another person or agency. (Community Care Services Eligibility Handbook 1145, When and What Information May Be Disclosed; Medicaid for the Elderly and People with Disabilities Handbook C-3000, When and What Information May Be Disclosed; Star Plus Handbook 2114, Information That May Be Disclosed; and Texas Works Handbook B-1220, Specific Information That May Be Released).
Number of Copies
Complete an original only.
The person completes the form and returns it to HHSC. The form may be mailed, faxed or returned to a local office.
Image and retain a copy of the form in the case record.
Case Name— Enter the name of the person associated with the case.
Case No.— Enter the case number.
Release of information— Enter the name of the person or the agency authorized to receive the person’s information. Check one of the following to indicate the information for release—Check the box that specifies the information the person authorizes for release.
Purpose(s) of Release— Enter a description of each purpose of the requested use or disclosure. The statement at the "request of the person" is a sufficient description of purpose when the person initiates the authorization and does not elect to provide a statement of purpose.
This authorization expires on— Enter an expiration date or an expiration event that relates to the person's case. Date cannot be more than 12 months from the signature date.
Statement of Understanding and Signature—The form must be signed by one of the following:
- The applicant or recipient or their authorized representative;
- The head of household or their spouse, if certified for SNAP;
- The caretaker, payee, or second parent, if certified for TANF or Children’s Medicaid.
Exception: If the person, head of household or their spouse, or a caretaker or second parent does not sign the form, an authorized representative must sign the form before protected health information is released.
Note: If someone other than the person associated with the case is signing the form, check the box below the signature line and enter why the representative has the authority to sign on behalf of the person. Documentation of authority to act may be requested.
Signatures of Witnesses— If the person requesting the release of case information cannot sign their name, two witnesses to the person's mark (X) must sign. Accept one witness signature in circumstances where it is not possible to obtain two witness signatures. Document the reason witness signatures are needed in the case record.
Date— Enter the date the form is signed.
Notice to Person—No action needed.