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

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

By signing this authorization form, you are giving the Texas Health and Human Services Commission (HHSC) permission to Preview on Page 1

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4.7 out of 5

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The document is an authorization form from the Texas Health and Human Services Commission allowing clients to permit the release of their Medicaid claims history, which includes protected health information. Clients can specify whether to release all or part of their claims history, designate a recipient for the information, and state the purpose for the release. The form also outlines the client's rights regarding revocation of consent and includes sections for client identification, signature, and witness if necessary.

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

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Versions	Form popularity	Fillable & printable
2017	4.3 Satisfied (24 Votes)
2015	4.4 Satisfied (32 Votes)
2004	4.7 Satisfied (21 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the form H1019 for Texas HHSC?

Purpose. To provide clients a form that lists their reporting requirements. To provide clients a form to report changes in their circumstances. To provide Texas Health and Human Services Commission (HHSC) office staff a form to record information reported by clients about changes in their circumstances.

What roles does the Texas Human Services Commission have in health care policy in Texas?

The Texas Health and Human Services Commission (HHSC) helps provide food, health care, safety and disaster assistance services to Texans. In addition to connecting people with a range of resources, the agency regulates health care providers, professions and facilities throughout the state.

How do I check the status of my Texas Health and Human Services commi claim?

Call 800-925-9126, Option 1 to check claim status, client eligibility, benefit limitations, current weekly payment amount, and claim appeals. Eligibility and claim status information is available 23 hours a day, 7 days a week, with scheduled down time between 3 a.m. and 4 a.m., Central Time.

How do I report changes to my Texas benefits?

Form H1855, Affidavit for Nonreceipt or Destroyed Supplemental Nutrition Assistance Program (SNAP) Benefits | Texas Health and Human Services.

What is the H1003 form for benefits in Texas?

The Form H1003 is a document used by the Texas Health and Human Services to collect information necessary for determining eligibility for various assistance programs. This form is essential for individuals seeking benefits related to health care, food assistance, and other social services.

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What events are reportable in Texas Health and Human Services?

Licensed or certified Texas Health and Human Services providers must notify the agency if someone in their care has been or may be physically or mentally abused, neglected or exploited. Depending on their reporting guidelines and HHS rules, providers may be required to report other incidents including: Deaths.

What is tx st hhsc?

Texas Health and Human Services, also known as the Texas Health and Human Services Commission (HHSC), helps more than 7.5 million Texans every month. The agency supports the needs of mothers, children and families through programs such as Medicaid, CHIP, SNAP, womens health and behavioral health services.

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