TX HHS Form 1022. Authorization to Disclose Information Including Protected Health Information for Referral to Another Agency/Organization

The TX HHS Form 1022 is an authorization form issued by the Texas Health and Human Services (HHS) for individuals to disclose their protected health information, including HIV/AIDS and alcohol/drug abuse treatment, to another agency or organization. This form enables expedited referral and coordination of services.

This form is designed for individuals who wish to authorize the disclosure of their health information to specific persons or agencies. The authorization can be revoked earlier if desired, and it expires on a specified date, event, or condition. The individual must sign the form, and in cases where they are unable to sign, two witnesses must attest to their mark (X).

The TX HHS Form 1022 also includes important notice provisions for individuals regarding the release of their health information. Once authorized, the information may no longer be protected by medical privacy laws, and recipients may not be legally required to keep it confidential. Individuals have the right to withdraw authorization in writing, request and review information obtained about them, and ask for corrections if necessary.