Form H3035, Medical Information Release and Disability Determination

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Effective Date

1/2026
H3035.pdf
H3035-S.pdf

Instructions

Updated: 1/2026

Purpose

Part 1 — Veteran Status
To determine if the applicant is a veteran of the U.S. Armed Forces.

Part 2 — Medical Information Release

  • Serve as an authorization to release medical information HHSC has about an applicant.
  • Authorizes HHSC to release medical information about an applicant to any federal or state agency or department where the applicant has applied for aid or services.
  • Releases HHSC, and the physician, hospital or institution from all legal responsibility and liability that may arise from release of information.

Procedure

When to Prepare

Complete Form H3035 for the applicant’s authorization to get medical information from an optometrist, physician, hospital, institution or other source, or to release information to other agencies.

In response to requests for copies of medical information from other agencies, release the information only if a properly executed Form H3035 or other appropriate release signed by the applicant is on file.

Transmittal

Send an original Form H3035 with each request for medical information.

Send the original Form H3035 and related medical information for imaging once the requested medical information is returned.

Detailed Instructions

Applicant Name — Enter the name of the applicant for Medicaid benefits.

Date of Birth — Enter the applicant's date of birth.

Social Security No. — Enter the patient's Social Security number.

Application or Case No. — If a case number has not been assigned, enter the application number.

Part 1 — Veteran Status

Check the box — Self-explanatory.

Part 2 — Medical Information Release

Section 1 –HHSC Completes

Applicant’s Name — Self-explanatory

DOB — Enter applicant’s date of birth.

List of patient's disabilities — Enter all medical or mental conditions told to eligibility specialist by the applicant. Remind the applicant to list in order all medical conditions that cause him or her to be disabled. This allows the doctor to release information on all impairments.

Section 2 –Applicant or applicant’s authorized representative completes

Applicant’s Name — Self-explanatory.

Authorization Release — Check all the boxes that apply. Enter the name of the doctor, medical facilities or other health providers on the appropriate lines.

This authorization expires on — Enter an expiration date or an expiration event that relates to the person.

Signature — Applicant or authorized representative's signature.

The applicant must sign all Forms H3035 except if the applicant:

  • is deemed mentally incompetent and a legal guardian was appointed. The guardian must sign for the applicant.
  • is 18 years or older, was deemed mentally incompetent, does not have a legal guardian and has not had a judicial restoration of their legal rights. The county judge must sign for the applicant.
  • is an unemancipated minor. The parent or managing conservator must sign, unless someone else is authorized to consent under Chapter 35 of the Texas Family Code.

Date — Enter the date the form is signed.

B-3000, Applications, for definitions.

Signatures of Witness — Enter the signatures of two witnesses, if required.