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

The TX HHS Form 6700, "Use and Release of Health Information Authorization", is a crucial document that enables individuals to authorize the release of their Medicaid claims history. This form helps solve the problem of sharing medical information with healthcare providers, insurance companies, or other authorized entities for specific purposes.

This authorization form requires key information from the individual, including their name, date of birth, and Medicaid ID number (if known). The form also features three main sections: Part A, which outlines the release of information; Part B, which specifies the purpose(s) of the release; and Part C, where the individual or legal authorized representative signs and dates the authorization. Notably, the form allows individuals to select one of three options for releasing their Medicaid claims history.

This form is commonly used in scenarios where an individual needs to share their medical information with a healthcare provider, insurance company, or other entity for treatment, payment, or healthcare operations purposes. The form also includes important notices to individuals regarding the use and release of their health information, including their right to withdraw permission and request corrections to incorrect information.