Form H1836-A, Medical Release/Physician's Statement

Instructions for Opening a Form

Some forms cannot be viewed in a web browser and must be opened in Adobe Acrobat Reader on your desktop system. Click here for instructions on opening this form.


Effective Date: 3/2015


Updated: 1/2006


  • To provide verification of an individual's disability;
  • To give information to the advisor concerning the extent of disability; or
  • To provide information to the local workforce board regarding the individual's ability to participate in work or work activities.


When to Prepare

Texas Works advisors prepare Form H1836-A for:

  • Supplemental Nutrition Assistance Program (SNAP) recipients who appear to be capable of employment but claim a disability;
  • TANF recipients who are claiming a temporary or permanent disability that affects their ability to work, participate in work activities or support their child(ren);
  • TANF recipients who are applying for a severe personal hardship exemption during the state time limit five-year freeze-out period; or
  • TANF recipients who are applying for an extended TANF personal disability hardship exemption during or after their 60th month of assistance.

Number of Copies

Prepare one copy.


The individual is responsible for taking Form H1836-A to a physician, physician's assistant (under physician's orders), advanced practice nurse, certified psychologist or a licensed osteopath. The medical provider completes the form and gives it to the individual, mails it in a return envelope or faxes a copy to the advisor.

If Form H1836-A is completed for a SNAP recipient, file a copy in the Employment Services section of the case record.

If Form H1836-A is completed for a TANF recipient, file a copy in the Medical section of the case record.

Form Retention

Refer to the Manager's Guide for Eligibility Programs.

Detailed Instructions

Section I — The advisor completes identifying case information.

Section II — The medical provider completes Part A by checking one box under question 1, 2 or 3.

If question 2 is checked, the provider must complete Part B and Part C.

If question 3 is checked, date and return the form to the local eligibility determination office.

The provider must sign, date and return the form to the local eligibility determination office.

Note: When a SNAP recipient claims that he is needed in the home to care for a disabled household member, the medical provider only needs to complete Part A for the disabled member.

Section III — The individual (or individual's personal representative) signs to authorize release of medical information to HHSC and the Texas Workforce Commission.

Patient's Name — Self-explanatory.

Authorization Release — Enter the name of the doctor, medical facility or other health care provider.

This authorization expires on — Enter "when benefits expire."

Signature — Individual or personal representative's signature.

Date — Enter the date the form is signed.

Personal Representative — Must be legally designated. Refer to Texas Works Handbook, B-1200, Confidentiality, for definitions.

Describe Authority — Describe why the representative has the authority to represent the individual. Refer to Texas Works Handbook, Section B-1200, Confidentiality, for definitions.

Signature of Witnesses — The signatures of two witnesses are entered if required.

Date — Date witnesses signed the form.