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

The TX HHS Form 2869 is a permission form that allows individuals to authorize the collection of their protected health information, including confidential and nonconfidential data. This form is typically used in situations where an individual needs to provide consent for the sharing of their medical records with healthcare providers, government agencies, or other organizations.

The form requires the individual's name, date of birth, last four digits of their Social Security number, and alternative contact information such as phone numbers and email addresses. It also outlines the purposes for which the protected health information may be used, including service planning and eligibility determination. The form emphasizes that the individual has the right to revoke their authorization at any time, but this revocation will not apply to information that has already been released.

The TX HHS Form 2869 is an essential tool for individuals who need to provide consent for the sharing of their protected health information. By understanding the purposes and conditions outlined in this form, individuals can make informed decisions about how their medical records are used. Key points to note include:

• The form requires individual's consent to collect and share protected health information.
• Protected health information may be shared with healthcare providers, government agencies, or other organizations for service planning and eligibility determination.
• Individuals have the right to revoke their authorization at any time, but this revocation will not apply to information that has already been released.