Form H1836-B at a glance
What it is: This is the Medical Release or Physician's Statement: the applicant is requesting an exemption from participating in the employment services program because they are needed in the home due to a disabling illness or injury.
A filled-in Form H1836-B example: the patient authorizes the release
How to fill out Form H1836-B, box by box
Tap a group of boxes to open it, and a picture to see it full size.
Section 1 - To Be Completed By Staff
Staff complete Section 1 with the Name of Patient, Date of Birth, Social Security No., Case Name, caregiver Case No., Patient's Usual Job, Advisor's Name, BJN, Office Area Code and Fax No., Office Street Address, City, State and ZIP Code, and Office Mail Code.
Part A - Caring For a Disabled Family Member
Fill Part A - Caring For a Disabled Family Member.
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 1.
Mark one of the following for to what extent the caregiver can work or participate in activities to prepare for work: 1. The caregiver can work, or participate in activities to prepare for work outside or inside of their home, full time.
2. (a) The caregiver can work or participate in activities to prepare for work outside of their home, part time at hours per week. (b) The caregiver can work or participate in activities to prepare for work inside of their home, part time at hours per week.
3. The caregiver cannot work or participate in activities. If you check this box, 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.
Provide more detail, if necessary.
Part B - Diagnosis
Under Part B - Diagnosis, write the Primary Disabling Diagnosis, the Secondary Disabling Diagnosis and Comments.
The physician writes the Office Street Address or P.O. Box, City, State and ZIP Code and the Office Area Code and Phone No., then fills in the Typed or Printed Name of Physician, signs the Signature of Physician, and writes the Date and License No.
Section 3 - Authorization to Release Medical Information
The patient or patient's personal representative completes Section 3 - Authorization to Release Medical Information.
Write the Patient's Name.
Write when this authorization expires on.
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 your health information as shown 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 or Physician's Statement, and release the information to HHSC and the Texas Workforce Commission to verify that the applicant is needed in the home due to my disabling illness or injury. They therefore cannot participate fully in the employment services program.
Sign on the Patient or Personal Representative's Signature line and write the Date. Describe your authority to act for the patient if you are signing for the patient.
If the person requesting the release of case information cannot sign their name, two witnesses to their mark (X) must sign below, each with the Date.
More rules for Form H1836-B
The second page is Form H1836-B, Page / 6-2025.
Sources
[1] Form H1836-B, Medical Release or Physician's Statement (the Official source link on this page).