Form 0011 "Consent to Transfer to a Texas State Operated Facility" - Texas

What Is Form 0011?

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.

Form Details:

  • Released on October 1, 2020;
  • The latest edition provided by the Texas Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 0011 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

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Download Form 0011 "Consent to Transfer to a Texas State Operated Facility" - Texas

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Form 0011
October 2020-E
Consent to Transfer to a Texas State Operated Facility
I am presently receiving treatment, rehabilitation or habilitation at [facility name], a facility operated or contracted by the state of
[state name].
I am requesting that a referral be made on my behalf to the state of Texas.
This form has been explained to me in a language I understand.
I understand I have the right to withdraw this consent at any time.
If I have a legally authorized representative, this has been explained to him or her.
Person/Legally Authorized Representative’s Signature
Date
Witness
Date
The sending state must include an Authorization for Release of Information which meets state and federal privacy
regulations.
Submit the completed form by email to:
Texas Interstate Compact Coordinator
Interstate_Compact_Coordination@hhsc.state.tx.us
or
by mail to:
Texas Interstate Compact Coordinator
701 W. 51st St.
Mail Code E-619
Austin, Texas 78751
Form 0011
October 2020-E
Consent to Transfer to a Texas State Operated Facility
I am presently receiving treatment, rehabilitation or habilitation at [facility name], a facility operated or contracted by the state of
[state name].
I am requesting that a referral be made on my behalf to the state of Texas.
This form has been explained to me in a language I understand.
I understand I have the right to withdraw this consent at any time.
If I have a legally authorized representative, this has been explained to him or her.
Person/Legally Authorized Representative’s Signature
Date
Witness
Date
The sending state must include an Authorization for Release of Information which meets state and federal privacy
regulations.
Submit the completed form by email to:
Texas Interstate Compact Coordinator
Interstate_Compact_Coordination@hhsc.state.tx.us
or
by mail to:
Texas Interstate Compact Coordinator
701 W. 51st St.
Mail Code E-619
Austin, Texas 78751