TX HHS Form 6700. Use and Release of Health Information Authorization

Form 6700, “Use and Release of Health Information Authorization,” is a document used in Texas to give the Health and Human Services Commission (HHS) permission to release a person’s Medicaid claims history. Because Medicaid claim data includes sensitive health information, Texas law requires a formal written authorization before any portion of this information can be shared. This form ensures that the individual understands what will be released, to whom it will be provided, and for what purpose.

Purpose of Form 6700

The primary function of Form 6700 is to authorize HHS to disclose protected Medicaid claims information. Individuals typically use this form when they need to provide their medical billing history to an attorney, an insurance company, a health care provider, or another party involved in a legal or administrative matter. The authorization can apply to all Medicaid claims or to only those related to a specific incident, provider, or injury. Because this information is highly regulated, the form helps protect the individual's privacy while ensuring compliance with state and federal laws, including HIPAA and Texas Government Code requirements.

Detailed Explanation of Each Section

Section I – Individual’s Information

This section identifies the person whose Medicaid information may be released. It includes the individual's name, date of birth, Social Security number, and Medicaid ID (if known). Providing accurate personal information is essential because HHS matches this data against state records before releasing any claims history.

• Common mistake: Incorrect birthdate or transposed Social Security digits, which can delay processing.
• Tip: Ensure all identifying numbers match official documents.

Section II – Release, Purpose and Authorization of Information

This part defines what information will be released, who will receive it, and why. It contains three subsections: Part A (specific information to release), Part B (purpose and expiration), and Part C (signature authorization).

Part A – Release of Information

The individual chooses whether to release:

• All Medicaid claims history;
• Only claims related to a specific injury or accident;
• Only claims linked to a named provider; or
• Another specific category of health information described in detail.

Next, the individual identifies the person or agency authorized to receive the information. This might include an attorney, an insurance adjuster, a caseworker, or a medical practice.

• Typical mistakes: Not clearly specifying the agency name, or giving an incomplete description when selecting “other.”

Part B – Purpose(s) of Release

This section explains why the release is needed. The form states that authorization expires six months after final disposition of the related claim or the disposition of Medicaid funds. This ensures the release is temporary and tied to a specific purpose, not open-ended.

Part C – Authorization and Signature

The individual signs and dates the form. If someone signs on their behalf—such as a legal guardian, power of attorney, or authorized representative—their authority must be described. A witness signature is required if the individual cannot sign their own name.

Section III – Notices to Individuals

This section outlines important legal notices, including:

• Once HHS releases information, it is no longer responsible for how the recipient uses or further discloses it.
• The individual may revoke the authorization in writing unless HHS has already acted on it.
• Individuals have the right to access and request corrections to their information under Texas Government Code.

Examples of Real-Life Situations Where Form 6700 Is Needed

• A personal injury attorney requests your Medicaid claims history to evaluate whether treatment costs relate to an accident.
• An insurance company needs documentation of medical expenses to process a liability or workers' compensation claim.
• A healthcare provider is verifying previous Medicaid-covered treatments to avoid duplicate billing.
• A caseworker is reviewing eligibility or compliance during a Medicaid-related investigation.

Documents Commonly Attached

• A copy of a government-issued ID
• Legal documents showing authority to sign (guardianship papers, power of attorney, etc.)
• Accident or injury reports if requesting release for a specific incident
• Correspondence from the requesting agency explaining why the information is needed

Practical Tips for Completing the Form

• Make sure names and identifying numbers are legible and accurate.
• Clearly specify which records you want released to avoid unnecessary delays.
• Double-check the spelling of the recipient’s name and agency.
• If someone signs for the individual, attach documents proving their authority.
• Keep a copy of the completed form for personal records.

Frequently Asked Questions (FAQ)

• Who can request the release of Medicaid claims history? Typically, the individual, a legal representative, an attorney, or an agency involved in a related matter.
• Does this form allow release of all medical records? No. It authorizes only the release of Medicaid claims data, not private health records held by providers.
• How long is the authorization valid? It expires six months after the related claim is resolved or Medicaid funds are settled.
• Can I revoke this authorization? Yes, as long as the revocation is in writing and HHS has not yet relied on the authorization.
• Will HHS notify me before releasing the information? Generally, no. The signed form itself serves as the authorization.
• What if I only want specific claims released? You may limit release to certain providers, injuries, or categories by completing Part A accordingly.
• What if the individual cannot sign? A witness may sign, and documentation showing authority to act for the individual may be required.

Micro-FAQ (Short Answers)

• What is the purpose? To authorize HHS to release Medicaid claims history.
• Who files? The individual or their legal representative.
• How long valid? Six months after the claim’s final disposition.
• What can be released? All or part of Medicaid claim records.
• Attachments? ID, legal authority documents, claim details.
• Where submitted? To Texas Health and Human Services (HHS).
• Can it be revoked? Yes, in writing.
• Is witness needed? Only if the individual cannot sign.
• Does it release full medical records? No, only Medicaid claims history.
• Is redisclosure controlled? No; recipient may further share the information.

Related Forms

• Texas Form H1826 – Case Information Release
• HIPAA Authorization Form (General)
• Texas Medicaid Provider Inquiry Forms

Form Details

• Form Name: Use and Release of Health Information Authorization
• Form Number: 6700
• Region: Texas
• Revision Date: August 2017
• Issuing Agency: Texas Health and Human Services (HHS)