Form H0401-S, HIPAA - Privacy Notice (Spanish)

Effective Date: 9/2004

Availability

PDF: H0401-S.pdf

Instructions

Updated: 12/2014

Purpose

  • The Health Insurance Portability and Accountability Act (HIPAA) is a federal law. HIPAA protects the privacy of medical information and gives recipients' privacy rights. The privacy notice describes their privacy rights. HIPAA requires that the Texas Health and Human Services Commission (HHSC) distribute the notice to Temporary Assistance for Needy Families (TANF), Supplemental Nutrition Assistance Program (SNAP) and Medicaid households at initial certification.
  • HHSC and all Medicaid agencies listed on the notice have a duty to protect the privacy of medical information.

Procedure

When to Prepare

Texas Works:

Provide Form H0401 to TANF, SNAP and Medicaid recipients at the time of initial certification.

Medicaid for the Elderly and People with Disabilities (MEPD):

Provide Form H0401 to all Medicaid recipients at the time of initial certification.

Number of Copies

Provide a copy of the privacy notice to one of the following:

  • Caretaker/payee or second parent (TANF/Medical Programs)
  • Head of the household or certified spouse (SNAP)
  • Authorized representative/responsible party (MEPD)

Transmittal

Provide the privacy notice at initial certification. In addition, provide Form H0403, HIPPA — Explanation of Health Information Privacy Rights, with Form H0401.

Form Retention

There is no retention requirement for this form.

Top of Page