Form 2076

Form 2076
Authorization to Release Medical Information
Individual's Name*
It is necessary for the Texas Health and Human Services Commission (HHSC) or a provider to verify your medical needs to determine your eligibility for services. When you sign this authorization, you are giving HHSC or a provider your permission to contact your doctors, medical facilities, or other health care providers and get copies of your health information as indicated below. Your signature is required on this authorization form to determine your eligibility for services.
I authorize: *
Type name of Doctors, Medical Facilities or Health Care Providers
and release the information to

Better At Home Care Texas, LLC List HHSC or Provider 12/31/2099
Individual or Personal Representative's Signature*

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Date*

MonthDayYear
Date
Individual or Personal Representative's Signature

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Date

MonthDayYear
Date
If you are signing for the individual, describe your authority to act for the individual
Note: If the person requesting the release of case information cannot sign his/her name, two witnesses must sign below:
Witness*
Date*

MonthDayYear
Date
Witness
Date

MonthDayYear
Date
HHSC or a provider, as receiver of this information, will protect your personal health information in accordance with federal and state privacy regulations. If you authorize release of your health information to other parties, it may no longer be protected by privacy regulations. You can withdraw the permission you have given your doctors, medical facilities, or other health care providers to use or disclose health information that identifies you, unless they have already taken action based on your permission. You must withdraw your permission in writing.
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