Form PERS-BSD-35 "Authorization to Disclose Protected Health Information" - California

What Is Form PERS-BSD-35?

This is a legal form that was released by the California Public Employees' Retirement System - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2019;
  • The latest edition provided by the California Public Employees' Retirement System;
  • 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 PERS-BSD-35 by clicking the link below or browse more documents and templates provided by the California Public Employees' Retirement System.

ADVERTISEMENT
ADVERTISEMENT

Download Form PERS-BSD-35 "Authorization to Disclose Protected Health Information" - California

Download PDF

Fill PDF online

Rate (4.7 / 5) 80 votes
Authorization to Disclose
Protected Health Information
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
Fax: (800) 959-6545
Member Information
Section 1
Name of Member (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy)
Section 2
Purpose of Authorization
The purpose for this authorization is to determine a physical or mental condition, illness, or
disability and the right, if any, to retirement, reinstatement, or other benefits under the Public
Employees’ Retirement Law (PERL) (Government Code sections 20000, et seq.) and the Public
Employees’ Medical and Hospital Act (PEMHCA) (Government Code sections 599.500, et seq.).
I,
(Name of Member or Authorized Representative), hereby
authorize
(Name of Health Care Provider/Facility or Physician)
to disclose protected health information to the California Public Employees’ Retirement System
(CalPERS) or its representative relating to
(Name of Member
or Disabled Dependent).
This authorization applies to any and all health and/or medical related information,
including the following:
Medical histories, diagnoses, examination reports, chart notes, testing and test results, X-rays,
operative reports, lab and medication records, prescriptions, and any other records relating to
the prognosis, treatment, or diagnosis of any condition.
Treatment records from mental health departments, alcohol/drug departments, or HIV antibody
tests are specifically protected. I authorize the release of the following by my initials and signature:
Mental health department records
Alcohol/drug dependency treatment records
HIV antibody test results
Signature of Member or Authorized Representative
Date (mm/dd/yyyy)
Dates of service for which I am authorizing release of information: From
to
(mm/dd/yyyy)
the present.
Expiration of Authorization:
Unless canceled by me in writing, this authorization shall be valid for four years from the date
shown below. A photocopy of this authorization shall be as valid as the original.
PERS-BSD-35 (12/20)
Page 1 of 2
Authorization to Disclose
Protected Health Information
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
Fax: (800) 959-6545
Member Information
Section 1
Name of Member (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy)
Section 2
Purpose of Authorization
The purpose for this authorization is to determine a physical or mental condition, illness, or
disability and the right, if any, to retirement, reinstatement, or other benefits under the Public
Employees’ Retirement Law (PERL) (Government Code sections 20000, et seq.) and the Public
Employees’ Medical and Hospital Act (PEMHCA) (Government Code sections 599.500, et seq.).
I,
(Name of Member or Authorized Representative), hereby
authorize
(Name of Health Care Provider/Facility or Physician)
to disclose protected health information to the California Public Employees’ Retirement System
(CalPERS) or its representative relating to
(Name of Member
or Disabled Dependent).
This authorization applies to any and all health and/or medical related information,
including the following:
Medical histories, diagnoses, examination reports, chart notes, testing and test results, X-rays,
operative reports, lab and medication records, prescriptions, and any other records relating to
the prognosis, treatment, or diagnosis of any condition.
Treatment records from mental health departments, alcohol/drug departments, or HIV antibody
tests are specifically protected. I authorize the release of the following by my initials and signature:
Mental health department records
Alcohol/drug dependency treatment records
HIV antibody test results
Signature of Member or Authorized Representative
Date (mm/dd/yyyy)
Dates of service for which I am authorizing release of information: From
to
(mm/dd/yyyy)
the present.
Expiration of Authorization:
Unless canceled by me in writing, this authorization shall be valid for four years from the date
shown below. A photocopy of this authorization shall be as valid as the original.
PERS-BSD-35 (12/20)
Page 1 of 2
Put your name and Social
Security number or CalPERS ID
Your Name
Social Security Number or CalPERS ID
at the top of every page.
Section 3
Acknowledgment and Signature
I acknowledge and understand the following:
I authorize the use and/or disclosure of the individually identifiable health information as
described above for the purpose listed. I understand that this authorization is voluntary.
I have the right to receive a copy of this authorization.
I have the right to revoke this authorization at any time by sending a signed notice to CalPERS
at the address below. The authorization will cease on the date my valid revocation release
is received.
This authorization may not be revoked if CalPERS has acted in reliance thereon, or the
authorization was obtained as a condition of obtaining insurance coverage.
Under California law, the recipient of my medical information is prohibited from re-disclosing
the information, except with a written authorization or as specifically required or permitted
by law.
My treatment, payment, enrollment, or eligibility for benefits will continue to be subject to
current policies and regulations if I do not sign this authorization.
If the organization or person I have authorized to receive the information is not a health
plan or health care provider, the released information may no longer be protected by federal
privacy regulations.
Signature of Member or Authorized Representative*
Date (mm/dd/yyyy)
*If this is a request from the Authorized Representative, please attach the member’s written
authorization or a copy of the applicable Power of Attorney or conservatorship document(s)
when returning the form.
Mail to:
California Public Employees’ Retirement System
P.O. Box 942715, Sacramento, California 94229
PERS-BSD-35 (12/20)
Page 2 of 2
Privacy Notice
The privacy of personal information is of the utmost importance to CalPERS.
The following information is provided to you in compliance with the Information
Practices Act of 1977 and the Federal Privacy Act of 1974.
Information Purpose
Social Security numbers are used for the
following purposes:
The information requested is collected pursuant
1.
Enrollee identification
to the Government Code (sections 20000 et seq.)
2. Payroll deduction/state contributions
and will be used for administration of Board
3. Billing of contracting agencies for employee/
duties under the Retirement Law, the Social
employer contributions
Security Act, and the Public Employees’ Medical
4. Reports to CalPERS and other state agencies
and Hospital Care Act, as the case may be.
5. Coordination of benefits among carriers
Submission of the requested information is
6. Resolving member appeals, complaints,
mandatory. Failure to comply may result in
or grievances with health plan carriers
CalPERS being unable to perform its functions
regarding your status.
Information Disclosure
Please do not include information that is
Portions of this information may be transferred
not requested.
to other state agencies (such as your employer),
physicians, and insurance carriers, but only
Social Security Numbers
in strict accordance with current statutes
regarding confidentiality.
Social Security numbers are collected on a
mandatory and voluntary basis. If this is CalPERS’
Your Rights
first request for disclosure of your Social Security
number, then disclosure is mandatory. If your
You have the right to review your membership
Social Security number has already been provided,
files maintained by the System. For questions
disclosure is voluntary. Due to the use of Social
about this notice, our Privacy Policy, or your rights,
Security numbers by other agencies for
please write to the CalPERS Privacy Officer at
identification purposes, we may be unable to
400 Q Street, Sacramento, CA 95811 or call us
verify eligibility for benefits without the number.
at 888 CalPERS (or 888-225-7377).
May 2016
Page of 3