TX HHS Form 0011. Consent to Transfer to a Texas State Operated Facility

The TX HHS Form 0011, Consent to Transfer to a Texas State Operated Facility, is a crucial document for individuals receiving treatment, rehabilitation, or habilitation at a state-operated facility. This form enables the individual to request a referral to another state-operated facility in Texas.

This consent form requires the individual's signature and date, as well as that of their legally authorized representative if applicable. The form also emphasizes the importance of understanding the contents and having the right to withdraw consent at any time. Additionally, the sending state must include an Authorization for Release of Information that meets state and federal privacy regulations.

Key requirements for completing this form include providing the facility name where treatment is being received, as well as submitting the completed form by email or mail to the Texas Interstate Compact Coordinator. The following key points summarize the use of this form:

• This form is used when an individual receiving treatment at a state-operated facility in Texas requests a referral to another state-operated facility.
• The form requires the individual's signature and date, as well as that of their legally authorized representative if applicable.
• Submission of the completed form by email or mail is required.