TX HHS Form 5021. HIPP Consent

The HIPP Consent Form (TX HHS Form 5021) is a crucial document that enables individuals to authorize another person to discuss their family's case with the Texas Health and Human Services (HHS) Premium Payment Health Insurance Premium Payment (HIPP) program. This form is typically filled out by the individual who has health insurance, allowing them to designate someone else to communicate on their behalf.

The HIPP Consent Form requires specific information, including the name of the person filling out the form, their case number, street address, apartment, city, state, and ZIP code. Additionally, the form asks for phone and email contact information. The individual must also specify who they authorize to discuss their family's case. Once completed, the form must be signed and dated by the authorized individual.

To complete the HIPP Consent Form, simply fill out the required information, sign and date the form, and return it to HHS via fax at 1-866-409-1188, email at [email protected], or mail to P.O. Box 201120 Austin, TX 78720-9774. If any changes occur, it is essential to notify HHS immediately. Key points and requirements include:

• Filling out the form authorizes another person to discuss your family's case with HIPP.
• The individual who has health insurance must fill out the form.
• The form must be signed and dated by the authorized individual.