TX HHS Form 3039. Authorization to Disclose Protected Health Information
Form 3039 is an official authorization document used in the Texas Home and Community-Based Services Adult Mental Health (HCBS-AMH) program. It allows an individual, or their authorized representative, to give written permission for specific protected health information to be shared with a designated person or organization.
This form is designed to meet federal privacy requirements and helps ensure that sensitive personal and health information is disclosed lawfully, transparently, and only for approved purposes.
Purpose of Form 3039
The main purpose of Form 3039 is to document informed consent for the release of protected health information (PHI). It provides a clear record of what information may be shared, who may receive it, and how it may be used.
In HCBS-AMH services, this form is often necessary to coordinate care, support eligibility reviews, or allow communication between providers, agencies, and support persons.
When This Form Is Required
Form 3039 is required whenever protected health information needs to be shared outside the entity that originally collected it. Common situations include:
- Coordinating services between multiple providers or agencies
- Sharing records with case managers, evaluators, or oversight entities
- Allowing a family member or representative to access health information
- Supporting program enrollment, monitoring, or service planning
The form is generally not required for internal use within a single covered entity when disclosure is permitted by law without authorization.
Who May Complete and Sign the Form
The form may be completed and signed by:
- The individual whose information is being disclosed
- A legally authorized personal representative acting on the individual’s behalf
If a personal representative signs the form, documentation proving legal authority must be attached.
Explanation of Each Key Section
Individual Identification
This section records the individual’s name, date of birth, Social Security number, and address. Accurate identification ensures the correct records are disclosed.
Authorizing Entity
The form specifies which organization or provider is authorized to release the information. This limits disclosure to the named entity only.
Types of Information to Be Disclosed
The individual selects which categories of information may be shared, such as:
- Medical or mental health records
- Legal information
- Incarceration history
- Psychological reports
- Social history
- Other specifically described information
Only the information explicitly authorized may be disclosed.
Recipient of Information
This section identifies the person or organization that will receive the information. Disclosure is limited to this named recipient.
Purpose of Disclosure
The form requires a stated purpose, helping ensure the information is used only for legitimate and agreed-upon reasons.
Individual Rights and Acknowledgments
This section explains important rights, including the right to revoke the authorization in writing and acknowledgment that disclosed information may be re-disclosed as permitted by law.
Expiration Date
An expiration date or event must be listed. If none is provided, the authorization automatically expires one year from the date of signature.
Signatures and Witness
The form must be signed and dated by the individual or personal representative, and witnessed as required. All blank fields must be completed or clearly marked before signing.
Practical Tips for Completing Form 3039
- Be specific when selecting the types of information to disclose.
- Clearly identify the receiving person or organization.
- Include an expiration date that reflects your actual needs.
- Attach proof of authority if signing as a representative.
- Keep a copy of the signed form for your records.
Common Mistakes to Avoid
- Leaving required fields blank
- Authorizing overly broad information unintentionally
- Failing to include an expiration date or event
- Not attaching proof of representative authority
- Using outdated contact or address information
Legal and Regulatory Context
Form 3039 complies with federal privacy requirements under the Health Insurance Portability and Accountability Act (HIPAA), specifically the authorization standards governing disclosure of protected health information. HCBS-AMH providers are required to obtain valid authorization before releasing PHI unless an exception applies.
Improper disclosure without authorization may result in compliance violations, penalties, or loss of program participation.
Real-Life Situations Where This Form Is Used
- An individual authorizes release of mental health records to a service coordinator.
- A provider shares records with a state oversight agency for program review.
- A legal representative accesses health information to support care planning.
- Records are released to support eligibility or service continuity.
Documents Commonly Attached to This Form
- Proof of legal authority for personal representatives
- Guardianship or power of attorney documentation
- Identification verification if required by the provider
Frequently Asked Questions
Is Form 3039 required to share health information?
Yes, unless disclosure is otherwise permitted by law.
Can the authorization be revoked?
Yes, it may be revoked in writing at any time.
Does signing affect eligibility or benefits?
No, it does not affect treatment or eligibility.
How long is the authorization valid?
Until the stated expiration date or one year if none is listed.
Can I limit what information is shared?
Yes, only selected categories may be disclosed.
Who keeps the completed form?
The provider releasing the information retains the form.
Related Forms
- HCBS-AMH Enrollment Forms
- Release of Information Revocation Forms
- Personal Representative Authorization Documents
- HIPAA Privacy Acknowledgment Forms
Form Details
- Form Name: Authorization to Disclose Protected Health Information
- Form Number: 3039
- Program: HCBS Adult Mental Health (HCBS-AMH)
- State: Texas
- Revision Date: December 2018