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

Effective Date: 9/2004


PDF: H0401-S.pdf


Updated: 7/2005


  • 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 Health and Human Services Commission (HHSC) distribute the notice to TANF, Food Stamp 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.


When to Prepare

Texas Works:

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


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:

  • the caretaker/payee or second parent (TANF/Medical Programs);
  • head of the household or certified spouse (Food Stamps); or
  • authorized representative/responsible party (LTC).


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

Form Retention

There is no retention requirement for this form.

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