TX HHS Form 3039. Authorization to Disclose Protected Health Information

The TX HHS Form 3039, Authorization to Disclose Protected Health Information, is a crucial document that helps individuals authorize the release of their protected health information to specific persons or entities. This form is typically used in situations where an individual needs to share their medical records with healthcare providers, insurance companies, or other relevant parties.

This authorization complies with the requirements of §164.508 of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Standards. The form requires the authorized person or entity to specify the type of protected health information they wish to disclose, including medical records, legal information, incarceration history, psychological reports, social history, and other relevant details. The recipient of this information is responsible for using it only for the specified purpose(s) outlined in the authorization.

The form also includes important conditions and follow-up actions. For instance, the authorized person or entity may revoke this authorization in writing by contacting the person or entity that obtained the authorization. Additionally, the expiration date of this authorization will be specified on the form. Key points to note include:

• This form is used to authorize the disclosure of protected health information.
• The authorized person or entity must specify the type of information they wish to disclose.
• The recipient of this information is responsible for using it only for the specified purpose(s).
• This authorization may be revoked in writing by contacting the person or entity that obtained the authorization.