TX HHS Form 2869. Permission to Collect Protected Health. Confidential and Nonconfidential Information

TX HHS Form 2869: Permission to Collect Protected Health, Confidential and Nonconfidential Information

This form is used to obtain permission from an individual or their authorized representative to collect protected health information, confidential and nonconfidential information for the purpose of developing a service plan. The form requires the individual's name, date of birth, last four digits of SSN, and other relevant details. It also outlines the purposes for which the collected information may be used, including eligibility determination and service planning.

The form highlights key sections such as the individual's acknowledgement of understanding regarding the collection and use of their protected health information. Additionally, it mentions the right to revoke this authorization at any time, with a valid revocation requiring written notice presented to the Texas Health and Human Services Commission. This form should be used when an individual needs to provide permission for the collection of their protected health information for service planning purposes.