Get Tx Hsa-27 2021-2025

This guide provides comprehensive instructions on how to fill out the TX HSA-27 online. It is designed to assist users in completing the form accurately and efficiently.

Follow the steps to successfully complete the TX HSA-27 form online.

1. Click the ‘Get Form’ button to access the TX HSA-27 form and open it in your preferred online editor.
2. Begin filling out the form by entering the patient’s full name in the designated field labeled 'Patient Name (print)'.
3. In the next field, enter the Offender Number, which is a unique identifier assigned to the patient.
4. Record the facility name where the patient is currently located in the section labeled 'Facility'.
5. Provide the patient's date of birth in the specified format to ensure correct identification.
6. Identify the person(s) or organization(s) authorized to receive the patient’s protected health information (PHI) by filling in the name(s) in the appropriate field.
7. Fill in the street address, city, state, and zip code of the authorized person or organization accurately.
8. Include the telephone and facsimile number of the authorized recipient for communication purposes.
9. Detail the specific type of information you are allowing to be disclosed by describing it in the designated area. Be as explicit as possible.
10. State the purpose of this authorization for releasing PHI in the provided section, selecting an appropriate reason such as 'continuity of patient care' or 'legal review'.
11. Review the consent regarding sensitive information, including AIDS, HIV, substance abuse, or mental health treatment, to confirm understanding.
12. Acknowledge the expiration of this authorization, stating it will remain valid for 730 days or until revoked. Specify any earlier expiration if needed.
13. Finalize the form by signing in the designated area, including the date of signing.
14. If applicable, print the name of the personal representative, if they signed on behalf of the patient.
15. Once the form is completed, ensure that all information is correct before saving your changes, and then download, print, or share the form as needed.

Complete and submit your TX HSA-27 form online to ensure proper processing of your authorization.