TX HHS Form 5025. HIPP Authorization for Use and Release of Health Insurance Information

The TX HHS Form 5025, HIPP Authorization for Use and Release of Health Insurance Information, is a crucial document that enables individuals to authorize Texas Health and Human Services (HHS) to access and release their employer-sponsored health insurance benefits and coverage information.

This form is typically used in situations where an individual needs to enroll or re-enroll in the Health Insurance Premium Payment (HIPP) program. By signing this authorization, clients grant HHS permission to release and access necessary information to determine eligibility for the program. The form also outlines the client's responsibilities, including the option to withdraw permission at any time.

Key features of this form include the required client information, such as name, date of birth, Medicaid number (if known), and SSN number. Additionally, clients must authorize HHS to release and access their information, which will expire once they are terminated from the HIPP program. If you have any questions or concerns about your rights under this form, please contact the HHS Privacy Office at 4900 N. Lamar Blvd., 4th Floor, Austin, Texas 78751, or call the HIPP Helpline at 1-800-440-0493.

• This form is used for enrollment or re-enrollment in the Health Insurance Premium Payment (HIPP) program.
• It authorizes Texas Health and Human Services (HHS) to access and release employer-sponsored health insurance benefits and coverage information.