We need your approval to share your complaint information

(Authorization to disclose information)

We might need to share information you give us in your complaint with the person or organization that your complaint is about. Some of the information we need to share might be:

Facts that ID you. For example, your address and birth date.
Your health information (if it applies to your compliant).
Other private facts about your case.

By law, we need your approval to share this information.

By checking “I approve” on the online complaint form:

You agree to allow us to share your health information (if it applies to your complaint) and other private facts you share on the complaint form.
You understand we might share your information with your insurance company and organizations covered in Texas Health and Safety Code section 181.154(c).
You understand we are not responsible for how your information is used by the people or organizations listed on your complaint form.

This approval will end if:

The person who has the complaint turns 18 years old (the complaint was filed for a person age 17 or younger).
The person who has the complaint tells us they no longer want to file a complaint.
The person who has the complaint dies.
or
You give us an end date for this approval.

You have the right to cancel or change this approval:

You must ask in writing if you want to:

Cancel this approval.
Give an end date for this approval.
Change who can get your health information and other private facts.

Email ConsumerProtection@tdi.texas.gov. Be sure to include your Complaint ID (you will get this number after you send your complaint to us).

Any actions taken and information shared before we get your email are covered by your approval on the online Complaint Portal.

We will need to send you another form and get your signature if:

The complaint includes:
- Mental health records (does not include psychotherapy notes).
- Genetic information and test results.
- Drug, alcohol, and substance abuse records.
- HIV / AIDS test results and treatments.
- Motor vehicle records.
The complaint is on behalf of a person who is age 17 or younger and we will need to share facts about:
- Birth control / reproductive care.
- Sexually transmitted diseases.
- Drug, alcohol, or substance abuse.
- Mental health treatment.