TX HHS Form 0003. Authorization to Furnish Information

Form 0003 is an official authorization document used by the Texas Health and Human Services Commission (HHSC). It allows an applicant or recipient of public assistance programs to grant permission for HHSC representatives to obtain information about their personal circumstances. This form is available in a bilingual format, including both English and Spanish versions, ensuring accessibility for a wider audience.

The primary purpose of this form is to verify eligibility for assistance by allowing HHSC to request relevant non-medical information from individuals, organizations, or entities that may hold records concerning the applicant or their household. Although the form authorizes the release of various types of information, it explicitly excludes the release of personal health information from doctors or other medical providers.

Purpose of the Form

Form 0003 serves as written consent from the applicant or recipient, giving HHSC permission to gather information that may influence eligibility for public assistance programs. This may include financial details, living arrangements, employment information, or other relevant records. Because HHSC relies on accurate and verified data to determine eligibility, this authorization is a critical component of the application process.

Who Uses This Form

• Applicants for Texas public assistance programs
• Current recipients undergoing eligibility reviews or updates
• Spouses of applicants or recipients, when applicable
• Individuals who need to authorize HHSC to contact third parties for information

Both the applicant and spouse may be required to sign the form if their circumstances are relevant to the eligibility determination.

Key Provisions of Form 0003

Authorization to Disclose Non-Medical Information

By signing the form, the applicant authorizes any person, organization, or establishment that holds information related to their circumstances to release such information to HHSC. This includes data that may reflect on the applicant’s qualifications for assistance, such as employment status, residence, household composition, or financial resources.

Explicit Exception for Medical Records

The form clearly states that this authorization does not permit any doctor or healthcare provider to disclose personal health information. Medical privacy laws continue to protect the applicant’s medical records unless a separate authorization is completed.

Bilingual Format

Form 0003 includes both English and Spanish text. The Spanish version (Forma 0003-S) provides the same legal authorization, ensuring that Spanish-speaking applicants clearly understand the rights they are granting and the limits of that authorization.

Information Required on the Form

• Name of the applicant or recipient
• Name of the spouse (if applicable)
• Residential address
• Signature(s) authorizing release of information
• Date of each signature

All fields must be completed accurately to ensure HHSC can use the authorization during the eligibility process.

When Form 0003 Is Needed

• When applying for public assistance through HHSC
• When undergoing a periodic eligibility review
• When HHSC needs to verify information through third-party sources
• When both applicant and spouse must provide consent for record access

Without a valid signed authorization, HHSC may be unable to collect necessary information, which can delay or impact eligibility decisions.

Form Details

• Form Name: Authorization to Furnish Information
• Form Number: 0003
• Language: Bilingual (English and Spanish)
• Issued by: Texas Health and Human Services Commission
• Edition Date: January 2015