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By signing this authorization form, you are giving the Texas Health and Human Services Commission (HHSC) permission to 2026
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How to use or fill out By signing this authorization form, you are giving the Texas Health and Human Services Commission (HHSC) permission to with our platform
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- Click ‘Get Form’ to open it in the editor.
- 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.
- 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.
- In Part A, specify the person or agency that will receive your information. If applicable, include the attorney or law firm representing you.
- Complete Part B by stating the purpose of the release and setting an expiration date for this authorization.
- Sign and date in Part C. If someone is signing on your behalf, provide their authority description below.
- If necessary, have a witness sign if you cannot sign your name.
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Related links
(d) A facility must maintain a completed and signed copy of the HHSC form in the individuals active record of the individual requesting authorization toRead more
Form H1003, Appointment of an Authorized Representative to Allow Another Person to Act for You. Click here for instructions on opening this form.