TX HHS Form 5021. HIPP Consent

The TX HHS Form 5021, HIPP Consent, is a document used to obtain consent from an individual or their representative to discuss their family's case with the Health Insurance Premium Payment (HIPP) program. This form is essential for those who want another person to be able to communicate with the HIPP program on their behalf.

The form requires the individual or their representative to provide specific information, including their name, HIPP case number, street address, apartment, city, state, and ZIP code, as well as their phone number and email. Additionally, they must identify who can be contacted about their family's case. The person signing the form must also sign and date it, indicating their agreement to allow the HIPP program to discuss their family's case with the listed individual.

This form should be used when an individual or their representative needs to grant permission for another person to communicate with the HIPP program on their behalf. The form can be submitted by fax at 1-866-409-1188, email to [email protected], or mailed to P.O. Box 201120, Austin, TX 78720-9774. For assistance, individuals can contact the HIPP Helpline at 1-800-440-0493 or use Relay Texas for speech or hearing impaired individuals.