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Laredo Texas Form Instructions 843: What You Should Know

I authorize release of medical information to the Texas Department of State Health Services to provide a comprehensive assessment of the client's health care needs; and a health care plan that is in the client's best interest in accordance with the client's medical plan options. I authorize publication of Texas State Health Services health care information on this website and request that all clients be notified of this publication. Furthermore, I authorize publication of Texas State Health Services health care information on this website and request that all clients be notified of this publication and be provided with a copy of the completed form. If this provision is not applicable to you, you may still be entitled to payment; as described later in this document. I understand that this information shall be used to determine and maintain eligibility of the client and provide the services specified in this order. If I choose to change plans or services, or wish to discontinue one or more of the following services I authorize Texas State Health Services in such manner as is necessary to ensure that the services I have authorized are administered according to Plan of Care. I authorize Texas State Health Services to administer medical, psychiatric, psychological and developmental services in accordance with the plans approved for the Client. I understand that this information shall be used to determine and maintain eligibility of the client and provide the services specified in this order. If I choose to change plans or services, or wish to discontinue one or more of the services I authorize Texas State Health Services in such manner as is necessary to ensure that the services I have authorized are administered according to Plan of Care. I authorize Texas State Health Services to administer medical, psychiatric, psychological and developmental services in accordance with the plans approved for the Client. I authorize Texas State Health Services to administer services as provided for by the Client. Furthermore, I have been informed by Texas State Health Services that they will need to contact me at least once every 6 months with progress reports and updates. Furthermore, I understand the costs of obtaining health records will exceed your initial fee. Furthermore, I understand that I have been advised not to obtain the information or forms from any other source in conjunction with my request. Furthermore, I further understand that it is not necessary for me to present this information at any point in time, and I am free to withdraw this authorization at any time. The Client's signature has been verified by the Texas State Health Services to authorize this release by Texas State Health Services of their written agreement.

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