Form H0003
08/2015
Agreement to release your facts
To find out if you can get or keep getting benefits, we must check facts about you.
Read and fill out this form.
My name (print):
Spouse's name (print):
I agree to allow the following organization to give facts or records about me or my spouse to the
Texas Health and Human Services Commission (HHSC):
• Employers
• Insurance companies
• Real estate companies
• Government agencies
• Building associations
• Banks or other financial institutions
• This agreement does not include getting personal health information from doctors or other health-care
providers.
• This agreement will not end until either:
o Your application for benefits is cancelled or not approved;
o You no longer get health-care benefits through HHSC or
o You send HHSC a written statement that says you no longer want HHSC to get your facts or
records. (If you don't allow HHSC to get your facts or records, you might not be able to get
benefits.)
Sign here:
Person applying for or getting benefits
Date
Spouse Date
Guardian, Power of Attorney, parent of minor child, or
authorized representative
Date
Return this form by:
1. Using the Your Texas Benefits app for iPhones and Androids (take photo of form, upload, and send);
2. Uploading it on YourTexasBenefits.com;
3. Faxing it to 1-877-447-2839 or
4. Mailing it to HHSC, PO Box 149027, Austin, TX 78714-9027.
