Form 3039 Authorization to Disclose Protected Health Information - Texas

What Is Form 3039?

This is a legal form that was released by the Texas Health and Human Services - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

FAQ

Q: What is Form 3039?
A: Form 3039 is the Authorization to Disclose Protected Health Information (PHI) in Texas.

Q: What is the purpose of Form 3039?
A: The purpose of Form 3039 is to obtain patient consent to disclose their protected health information to others.

Q: Who needs to fill out Form 3039?
A: The patient or their legal representative needs to fill out Form 3039.

Q: What information is required on Form 3039?
A: Form 3039 requires the patient's name, date of birth, contact information, the information to be disclosed, and the purpose of the disclosure.

Q: Are there any fees associated with submitting Form 3039?
A: No, there are no fees associated with submitting Form 3039.

Q: What happens after Form 3039 is submitted?
A: After Form 3039 is submitted, the healthcare provider can disclose the patient's protected health information as authorized.

Q: How long is Form 3039 valid for?
A: Form 3039 is valid for one year from the date it is signed, unless a different time period is specified.

Q: Can Form 3039 be revoked?
A: Yes, the patient or their legal representative can revoke Form 3039 at any time.

Q: Is Form 3039 specific to Texas?
A: Yes, Form 3039 is specific to Texas and follows the state's laws and regulations regarding the disclosure of protected health information.