By signing this authorization form, you are giving the Texas Health and Human Services Commission (HHSC) permission to 2026

1. Click ‘Get Form’ to open it in the editor.
2. In Section I, enter your name, date of birth, Medicaid ID number (if known), and Social Security Number. This information is essential for identifying your records.
3. Proceed to Section II. Here, authorize HHSC to release your information by filling out Part A. Choose whether to release all of your Medicaid claims history or only specific parts related to a healthcare provider.
4. In Part A, specify the person or agency that will receive your information. If applicable, include the attorney or law firm representing you.
5. Complete Part B by stating the purpose of the release and setting an expiration date for this authorization.
6. Sign and date in Part C. If someone is signing on your behalf, provide their authority description below.
7. If necessary, have a witness sign if you cannot sign your name.

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