Form H1836-B - Medical Release/physician'S Statement - Texas Page 2
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2Form H1836-B
Page 2/01-2006
Authorization to Release Medical Information
Section III – To Be Completed By Patient or Patient’s Personal Representative
Patient’s Name
The applicant is requesting an exemption from participating in the employment services program because he/she is needed in the home due to your
disabling illness or injury. When you sign this authorization, you are giving HHSC permission to contact your doctors, medical facilities or other
health care providers to request copies of you health information as indicated below. You must sign this form if you want the applicant to be eligible
for an exemption from the employment services program.
I authorize
Doctor, Medical Facilities or other Health Care Providers
to complete Form H1836-B, Medical Release/Physician’s Statement, and release the information to HHSC and the Texas Workforce Commission for
purposes of verifying that the applicant is needed in the home due to my disabling illness or injury, and therefore cannot participate fully in the
employment services program.
This authorization expires on
Patient or Personal Representative’s Signature
Date
If you are signing for the patient, please describe your authority to act for the patient:
Note: If the person requesting the release of case information cannot sign his/her name, two witnesses to his/her mark (X) must sign below:
Witness
Date
Witness
Date
Notice to Client
HHSC, 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 permission you have given your doctor or health care provider 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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