Form H1836-B, 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: 1/2006


Updated: 1/2006


  • To provide verification of a TANF/food stamp recipient's need to be in the home to care for a disabled family member; and/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-B for:

  • TANF/Supplemental Nutrition Assistance Program (SNAP) recipients who are claiming an inability to work or participate in work activities because they are needed in the home to care for an incapacitated family member;
  • TANF recipients who are applying for a hardship exemption, due to a disabling illness or injury of a family member during the state time limit five-year freeze-out period; or
  • TANF recipients who are applying for an extended TANF hardship exemption, due to caring for a disabled family member during or after their 60th month of assistance.

Number of Copies

Prepare one copy.


The individual is responsible for taking Form H1836-B 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 client, mails it in a return envelope or faxes a copy to the advisor.

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 indicate the number of hours per week the client is available for work or work activities.

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

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.

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

Date — Date witnesses signed the form.