Form H1836 B PDF Details

In navigating the Texas Health and Human Services Commission's requirements, the Form H1836-B emerges as a crucial instrument for caregivers applying for benefits. Drafted to address the complexities surrounding individuals who cannot engage in work due to their commitment to caring for family members with disabling conditions, this form serves a dual purpose. Firstly, it allows staff to process applications by collating essential details about the patient, including their name, date of birth, and social security number, as well as information regarding the caregiver. Secondly, it grants physicians a structured method to submit medical assessments pertinent to the caregiver's eligibility to work or partake in work-preparation activities. This form intricately details the degree to which a caregiver is available for employment, considering the demands of their caregiving role, and outlines the patient's primary and secondary disabling diagnoses as evaluated by a physician. Additionally, the inclusion of an authorization section for the patient or patient's representative emphasizes the sensitive nature of disclosing medical information, ensuring that consent is duly recorded. This built-in safeguard mirrors the broader regulatory environment's commitment to privacy, as underscored by stipulations for withdrawing consent. By interweaving medical assessments with formal consent, Form H1836-B reflects a critical balance between facilitating benefit applications and upholding the confidentiality of health information.

QuestionAnswer
Form NameForm H1836 B
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform 1836, h1836 b, 1836b form hhsc, 1836b form

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Texas Health and Human

Services Commission

Section I — To Be Completed By Staff

Medical Release/Physician’s Statement

Form H1836-B

January 2006

Name of Patient

Date of Birth

Social Security No.

 

 

- -

Case Name (caregiver)

Case No.

Patient’s Usual Job

 

 

 

Advisor’s Name

BJN

 

 

 

 

Office Address/Mail Code/Fax No.

 

 

 

 

 

Section II — To Be Completed By Physician

 

 

The person caring for the patient named above has applied for benefits with our agency. Federal and state regulations require that persons receiving

benefits work or participate in activities to prepare them for work unless they are unable to do so due to a circumstance such as being needed in the home due to the patient’s disabling illness or injury. This person claims that circumstance. Please complete parts A and B below. After you complete the form,

you may give it to the person or mail it to HHSC at the address in Section I.

Part A – Caring For a Disabled Family Member

To what extent is the caregiver able to work or participate in activities to prepare for work? Please check one of the following boxes:

1.

The caregiver is able to work, or participate in activities to prepare for work (outside or inside of their home), full time

 

 

 

2.

 

 

(a) The caregiver is able to work or participate in activities to prepare for work (outside of their home), part time at

 

 

hours/week

 

 

 

 

 

 

 

(b) The caregiver is able to work or participate in activities to prepare for work (inside of their home), part time at

 

 

hours/week

 

 

 

 

3.

The caregiver is unable to work or participate in activities. If you check this box, please indicate which of the following applies:

 

 

 

(a) The disability is permanent.

 

 

 

 

 

 

(b) The disability is not permanent and is expected to last more than 6 months.

 

 

 

 

 

 

 

 

 

 

 

 

(c) The disability is not permanent and is expected to last 6 months or less.

 

 

 

 

 

 

 

 

 

If necessary, provide further detail:

Part B– Diagnosis

Primary disabling diagnosis

Secondary disabling diagnosis

Comments:

Name of Physician (please type or print)

Physicians License No.

 

 

 

Signature-Physician

Date

 

 

 

 

Office Address (Street or P.O. Box, City, State, ZIP)

 

Area Code and Telephone No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form H1836-B

Page 2/01-2006

Authorization to Release Medical Information

Section III – To Be Completed By Patient or Patient’s Personal Representative

Patient’s Name

The applicant is requesting an exemption from participating in the employment services program because he/she is needed in the home due to your disabling illness or injury. When you sign this authorization, you are giving HHSC permission to contact your doctors, medical facilities or other health care providers to request copies of you health information as indicated below. You must sign this form if you want the applicant to be eligible for an exemption from the employment services program.

I authorize

Doctor, Medical Facilities or other Health Care Providers

to complete Form H1836-B, Medical Release/Physician’s Statement, and release the information to HHSC and the Texas Workforce Commission for purposes of verifying that the applicant is needed in the home due to my disabling illness or injury, and therefore cannot participate fully in the employment services program.

This authorization expires on

Patient or Personal Representative’s Signature

 

Date

If you are signing for the patient, please describe your authority to act for the patient:

Note: If the person requesting the release of case information cannot sign his/her name, two witnesses to his/her mark (X) must sign below:

Witness

Date

Witness

Date

Notice to Client

HHSC, as receiver of this information, will protect your personal health information in accordance with federal and state privacy regulations. If you authorize release of your health information to other parties, it may no longer be protected by privacy regulations.

You can withdraw permission you have given your doctor or health care provider to use or disclose health information that identifies you, unless they have already taken action based on your permission. You must withdraw your permission in writing.

How to Edit Form H1836 B Online for Free

Whenever you need to fill out 1836b form, you don't have to download and install any software - simply try our PDF tool. In order to make our tool better and simpler to utilize, we continuously design new features, taking into consideration feedback coming from our users. To get the ball rolling, consider these easy steps:

Step 1: Access the PDF form inside our editor by clicking on the "Get Form Button" above on this webpage.

Step 2: The editor will allow you to modify your PDF in various ways. Improve it by adding personalized text, correct what's already in the PDF, and include a signature - all within the reach of a couple of mouse clicks!

If you want to fill out this PDF form, make certain you provide the right details in each blank:

1. It is very important fill out the 1836b form properly, thus be careful when filling in the areas that contain all of these blanks:

Filling in section 1 of hhsc 1836 form

2. The third step is to fill in all of the following fields: If necessary provide further detail, Part B Diagnosis, Primary disabling diagnosis, Comments, Secondary disabling diagnosis, Name of Physician please type or, Physicians License No, Office Address Street or PO Box, SignaturePhysician, Date, and Area Code and Telephone No.

Part number 2 for filling in hhsc 1836 form

3. This next stage is going to be simple - fill in all the blanks in Section III To Be Completed By, Patients Name, The applicant is requesting an, I authorize, Doctor Medical Facilities or other, to complete Form HB Medical, This authorization expires on, Patient or Personal, Date, If you are signing for the patient, Note If the person requesting the, Witness, and Date to finish this process.

Best ways to fill in hhsc 1836 form portion 3

It is easy to make a mistake when filling in your Patient or Personal, thus make sure that you reread it before you'll send it in.

4. Completing Notice to Client, Witness, Date, HHSC as receiver of this, and You can withdraw permission you is key in the next step - make certain that you spend some time and take a close look at every blank area!

hhsc 1836 form completion process described (stage 4)

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