TX HHS Form 3039. Authorization to Disclose Protected Health Information

TX HHS Form 3039, "Authorization to Disclose Protected Health Information," is a crucial document that enables individuals or entities to authorize the disclosure of specific protected health information. This form helps solve the problem of obtaining consent for sharing confidential medical records with third parties, such as healthcare providers, insurance companies, or law enforcement agencies.

This authorization complies with HIPAA Privacy Standards and requires the individual or entity seeking disclosure to provide their name, address, city, state, and ZIP code. The form also specifies the type of protected health information that may be disclosed, including medical records, legal information, incarceration history, psychological reports, social history, and other specified information.

The key feature of this form is its flexibility in allowing individuals or entities to authorize disclosure for various purposes, such as treatment, payment, enrollment, or eligibility for benefits. The authorization can be revoked in writing at any time by contacting the person or entity that obtained the authorization. The form also includes an expiration date, which ensures that the authorization remains valid only for a specified period.