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

The TX HHS Form 1022 is a crucial document that enables individuals to authorize the disclosure of their health information for referral purposes. This form helps solve the problem of facilitating communication between healthcare providers, social services agencies, and other organizations involved in an individual's care. Typically, this form is completed by the individual themselves or their personal representative.

This authorization form requires the individual to specify which type of information they are willing to disclose, including protected health information. The form also outlines conditions under which the authorization may be revoked, such as expiration dates or specific events. Additionally, it emphasizes the individual's right to withdraw their authorization in writing and request corrections to incorrect information.

Key features of this form include the requirement for the individual's signature, as well as the option for a personal representative to sign on their behalf. The form also includes a notice section that informs the individual about their rights regarding the disclosure of their health information. By completing this form, individuals can facilitate smoother referrals and coordination of services with other agencies or organizations.

• This form is used for referral purposes to expedite an individual's care and coordinate services with other agencies or organizations.
• The individual must specify which type of information they are willing to disclose, including protected health information.
• The authorization may be revoked under certain conditions, such as expiration dates or specific events.