How to Sign Texas HHSC Form H0003: Agreement to Release Your Facts

Texas HHSC Form H0003, “Agreement to Release Your Facts,” is the written consent that lets the Texas Health and Human Services Commission contact outside organizations, such as your employer or bank, to verify information about your eligibility for state benefits like SNAP, Medicaid, or TANF. In most cases an HHSC caseworker prepares the form during the eligibility process and you, your spouse, or an authorized representative sign it.1Texas Health and Human Services. Form H0003, Agreement to Release Your Facts

What Your Signature Authorizes

Signing H0003 allows the following types of organizations to share facts or records about you or your spouse with HHSC:2Your Texas Benefits. Form H0003 – Agreement to Release Your Facts

  • Employers
  • Insurance companies
  • Real estate companies
  • Government agencies
  • Building associations
  • Banks and other financial institutions

The form does not cover personal health information from doctors or other healthcare providers. If HHSC needs medical records to decide a healthcare-related benefit, a separate authorization is required. What H0003 reaches is the financial and household information these organizations hold: pay stubs, account balances, insurance policy details, and similar records.2Your Texas Benefits. Form H0003 – Agreement to Release Your Facts

Who Fills It Out

You usually don’t complete most of this form yourself. When verbal authorization from a third-party source isn’t enough, HHSC staff prepare Form H0003 and fill in the identifying information at the top, including the organization being contacted and the facts being verified.1Texas Health and Human Services. Form H0003, Agreement to Release Your Facts The caseworker then presents it for your signature. HHSC policy prohibits staff from asking you to sign blank forms for future use.3Texas Health and Human Services. C-930, Providing Verification

The printed form has fields for your name and your spouse’s name. It does not ask for your Social Security Number or HHSC case number; the caseworker ties the form to your case file internally.2Your Texas Benefits. Form H0003 – Agreement to Release Your Facts A “Return this form by” field at the top shows the deadline for sending the signed copy back.

Who Can Sign

Form H0003 has three signature lines at the bottom:2Your Texas Benefits. Form H0003 – Agreement to Release Your Facts

  • The person applying for or receiving benefits
  • The spouse, if the spouse’s records are also being released
  • A guardian, power of attorney, parent of a minor child, or authorized representative signing on the applicant’s behalf

If someone signs as a guardian, power of attorney, or authorized representative, HHSC needs proof of that legal standing. Acceptable proof includes a court-ordered guardianship or power of attorney document, a signed Form H1003 (Appointment of an Authorized Representative), or a letter naming the representative that contains the applicant’s signature along with the representative’s name, address, and signature.4Texas Health and Human Services. A-170, Authorized Representatives Parents signing for minor children generally don’t need separate paperwork, because the parent-child relationship is already established through the benefits application.

How to Submit the Signed Form

HHSC accepts the signed form four ways:5Texas Health and Human Services. Benefits Application Next Steps

  • Upload a scanned copy or clear photograph through your account at YourTexasBenefits.com
  • Fax it to 877-447-2839
  • Mail it to HHSC, P.O. Box 149027, Austin, TX 78714-9027
  • Deliver it in person to any local HHSC benefits office, which you can locate through the HHS Locations page6Texas Health and Human Services. HHS Locations

Faxing or uploading online is the fastest route to your caseworker. If you mail the form, add a few days for delivery. Keep a copy either way, so you have proof of what you signed and when if the original gets lost.

How Long It Lasts and How to Cancel It

Form H0003 has no fixed expiration date. The agreement stays in effect until one of three things happens:2Your Texas Benefits. Form H0003 – Agreement to Release Your Facts

  • Your application for benefits is cancelled or not approved
  • You no longer receive healthcare benefits through HHSC
  • You send HHSC a written statement saying you no longer want the commission to obtain your facts or records

To revoke the authorization yourself, send a written statement with your full name that clearly states you no longer want HHSC to collect your facts or records. You can submit the revocation through the same channels used for the original form: online upload, fax to 877-447-2839, mail to the Austin P.O. Box, or hand-delivery to a local office.5Texas Health and Human Services. Benefits Application Next Steps The cancellation only takes effect once HHSC receives it, and any information already collected while the agreement was active remains in your case file.

The form itself cautions that withdrawing consent may affect your ability to receive benefits, because HHSC relies on these outside sources to verify eligibility. If the commission can’t confirm the facts it needs, it may not be able to approve or continue your case.2Your Texas Benefits. Form H0003 – Agreement to Release Your Facts