Form CDCR7385 "Authorization for Release of Protected Health Information" - California

What Is Form CDCR7385?

This is a legal form that was released by the California Department of Corrections & Rehabilitation - 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 November 1, 2014;
  • The latest edition provided by the California Department of Corrections & Rehabilitation;
  • 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 CDCR7385 by clicking the link below or browse more documents and templates provided by the California Department of Corrections & Rehabilitation.

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Download Form CDCR7385 "Authorization for Release of Protected Health Information" - California

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STATE OF CALIFORNIA
DEPARTMENT OF CORRECTIONS AND REHABILITATION
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
CDCR 7385 (Rev. 11/14)
Form: Page 1 of 2
Instructions: Pages 3 & 4
All sections must be completed for the authorization to be honored. Use "N/A" if not applicable.
I. Patient Information
Last Name:
First Name:
Middle Name:
CDCR #:
Date of Birth:
Street Address:
City/State/Zip:
II. Individual/Organization Authorized to Release Personal Health Records if Other Than CDCR
Name:
Address:
City/State/Zip:
III. Individual/Organization to Receive the Information
[45 C.F.R. § 164.508(c)(1)(ii), (iii) & Civ. Code § 56.11(e), (f)]
The undersigned hereby authorizes CDCR's Health Information Management to release the below health information pursuant to this
authorization.
Relationship to Inmate:
Name:
Address:
City/State/Zip:
Phone:
Fax:
IV. Authorization Expiration Event or Expiration Date for Release of Verbal Information/
Written Correspondence
[45 C.F.R. § 164.508(c)(1)(v) & Civ. Code § 56.11(h)]
Unless otherwise revoked by the inmate, this authorization for the release of my health care information to
the above-named person or organization will expire upon (choose one):
Date (mm/dd/yyy):
Release from Custody
Happening/conclusion of this event:
(e.g., conclusion of litigation, completion of surgery)
V. Hardcopy Health Care Records to be Released
[45 C.F.R. § 164.508(c)(1)(i) & Civ. Code § 56.11(d), (g)]
A separate authorization is required for each request to release hardcopy records. Records for the following
period of time are requested (must be completed to receive records):
From
:
To
:
(mm/dd/yyyy)
(mm/dd/yyyy)
Medical Services
Dental Services
Mental Health Services
Communicable Disease
Genetic Testing
HIV Test Results
Substance Abuse/Alcohol
Other:
Requests for Psychotherapy Notes require a separate CDCR 7385 in order to be fulfilled and may
not be combined with any other request for health care records.
Psychotherapy Notes
STATE OF CALIFORNIA
DEPARTMENT OF CORRECTIONS AND REHABILITATION
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
CDCR 7385 (Rev. 11/14)
Form: Page 1 of 2
Instructions: Pages 3 & 4
All sections must be completed for the authorization to be honored. Use "N/A" if not applicable.
I. Patient Information
Last Name:
First Name:
Middle Name:
CDCR #:
Date of Birth:
Street Address:
City/State/Zip:
II. Individual/Organization Authorized to Release Personal Health Records if Other Than CDCR
Name:
Address:
City/State/Zip:
III. Individual/Organization to Receive the Information
[45 C.F.R. § 164.508(c)(1)(ii), (iii) & Civ. Code § 56.11(e), (f)]
The undersigned hereby authorizes CDCR's Health Information Management to release the below health information pursuant to this
authorization.
Relationship to Inmate:
Name:
Address:
City/State/Zip:
Phone:
Fax:
IV. Authorization Expiration Event or Expiration Date for Release of Verbal Information/
Written Correspondence
[45 C.F.R. § 164.508(c)(1)(v) & Civ. Code § 56.11(h)]
Unless otherwise revoked by the inmate, this authorization for the release of my health care information to
the above-named person or organization will expire upon (choose one):
Date (mm/dd/yyy):
Release from Custody
Happening/conclusion of this event:
(e.g., conclusion of litigation, completion of surgery)
V. Hardcopy Health Care Records to be Released
[45 C.F.R. § 164.508(c)(1)(i) & Civ. Code § 56.11(d), (g)]
A separate authorization is required for each request to release hardcopy records. Records for the following
period of time are requested (must be completed to receive records):
From
:
To
:
(mm/dd/yyyy)
(mm/dd/yyyy)
Medical Services
Dental Services
Mental Health Services
Communicable Disease
Genetic Testing
HIV Test Results
Substance Abuse/Alcohol
Other:
Requests for Psychotherapy Notes require a separate CDCR 7385 in order to be fulfilled and may
not be combined with any other request for health care records.
Psychotherapy Notes
STATE OF CALIFORNIA
DEPARTMENT OF CORRECTIONS AND REHABILITATION
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
CDCR 7385 (Rev. 11/14)
Form: Page 2 of 2
Instructions: Pages 3 & 4
All sections must be completed for the authorization to be honored. Use "N/A" if not applicable.
VI. Purpose for the Release or Use of the Information
[45 C.F.R. § 164.508(c)(1)(iv)]
Health Care
Personal Use
Legal
Other (please specify):
VII. Authorization Information
I understand the following:
1. I authorize the use or disclosure of my individually identifiable protected health information
as described above for the purpose listed. I understand this authorization is voluntary.
2. I have the right to revoke this authorization. To do so I understand I can sign a
cancellation notice and send it to my current institution's Health Information Management
(health records). The authorization will stop further release of my protected health
information on the date my valid revocation request is received by Health Information
Management. [45 C.F.R. § 164.508(c)(2)(i)]
3. I am signing this authorization voluntarily and understand that my health care treatment
will not be affected if I do not sign this authorization. [45 C.F.R. § 164.508(c)(2)(ii)]
4. Under California law, the recipient of the protected health information under the
authorization is prohibited from re-disclosing the protected health information, except with a
written authorization or as specifically required or permitted by law. [Civ. Code § 56.13]
5. If the organization or person I have authorized to receive the protected health information
is not a health plan or health care provider, the released information may no longer be
protected by federal and state privacy regulations. [45 C.F.R. § 164.524(a)(2)(v)]
6. I have the right to receive a copy of this authorization. [45 C.F.R. § 164.508(c)(4) & Civ.
Code § 56.11(i)]
7. Reasonable fees may be charged to cover the cost of copying and postage related to
releasing this protected health information. [45 C.F.R. § 164.524(c)(4) et seq. & California
Health and Safety Code § 123110, et seq.]
VIII. Patient Signature
[45 C.F.R. § 164.508(c)(1)(vi) & Civ. Code § 56.11(c)(1)]
Name (Print):
Signature:
Date:
STATE OF CALIFORNIA
DEPARTMENT OF CORRECTIONS AND REHABILITATION
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
CDCR 7385 (Rev. 11/14)
Instructions
Note: Part IV is the request for release of verbal health care information or health care information as part of
written correspondence, and Part V is the request for release of paper health care records.
Part I - “Patient Information”: Records the patient's full name (last, first, and middle), CDCR number, date of birth,
and address if he/she is paroled or released (incarcerated patients do not need to provide an address).
Part II - "Individual/Organization to Release Personal Health Records if Other Than CDCR": Records the name
and address of the individual or organization to release personal health records if other than CDCR.
Part III - “Individual/Organization to Receive the Information”: Records who is to receive the information.
Part IV - “Authorization Expiration Event or Expiration Date for Release of Verbal Information/Written
Correspondence”: Used by the patient to limit the time period during which information may be shared. The patient
selects one of the three check boxes.
• If the “Date” check box is selected, the patient enters the date he/she wants the authorization to expire.
• If the “Happening/conclusion of this event” check box is selected, the patient enters the event he/she wants the
authorization to expire upon. This must be an event from which a date can be established.
Part V - “Hardcopy Health Care Records to be Released”: Contains a designated line for the date range of
hardcopy health care records to be released.
The bottom half contains nine check boxes. Patients check the boxes to release each specific type of information as
detailed below:
• “Medical Services” is checked when the patient wishes to have information released related to medical care.
• “Dental Services” is checked when the patient wishes to have information released related to dental treatment.
• “Mental Health Services” is checked when the patient wishes to have information released related to mental
health.
• “Communicable Disease” is checked when the patient wishes to have information released related to
communicable disease testing and treatment. Communicable disease includes sexually transmitted infections.
• “Genetic Testing” is checked when the patient wishes to have information released related to genetic testing.
• “HIV Test Results” is checked when the patient wishes to have HIV test results released.
• “Substance Abuse/Alcohol” is checked when the patient wishes to have substance abuse/alcohol records
released.
• “Other” is checked when the patient wishes to further restrict or further authorize the release of his/her medical
information, and he/she is to write those wishes on the line provided.
• “Psychotherapy Notes” is checked when the patient wishes to have psychotherapy notes released.
Requests for psychotherapy notes require a separate CDCR 7385 and may not be combined with any other
request for health care records.
Under HIPAA, there is a difference between regular personal health information and psychotherapy notes. The
following is HIPAA's definition of psychotherapy notes (§164.501):
Psychotherapy notes means notes recorded (in any medium) by a health care provider who is a mental health
professional documenting or analyzing the contents of conversation during a private counseling session or a group,
joint, or family counseling session and that are separated from the rest of the individual's medical record.
Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the
modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items:
diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.
STATE OF CALIFORNIA
DEPARTMENT OF CORRECTIONS AND REHABILITATION
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
CDCR 7385 (Rev. 11/14)
Instructions (continued)
Part VI - “Purpose for the Release or Use of the Information”: Should have at least one box checked. The patient
may utilize this section to check the provided boxes or select “Other” and describe the reason(s) he/she wants to
have the information released. If the patient does not want to designate a purpose, he/she may check the “Other” box
and state “At the request of the individual authorizing the release.”
Part VII - “Authorization Information”: Below this section are seven points which detail patient rights in regard to
authorizing release of information.
1. Tells the patient that he/she is giving authorization voluntarily.
2. Explains how to stop this authorization. The patient may revoke the authorization by sending a notice stopping
the authorization to the institution's Health Information Management. The authorization will be removed from
the patient's medical record when the revocation is received by Health Information Management.
3. Explains that signing this authorization is voluntary and will not affect treatment.
4. Explains that the recipient of the protected health care information under the authorization is prohibited from re-
disclosing the information, except with a written authorization from the patient or as specifically required under
law.
5. Explains that the released information may no longer be protected by federal privacy regulations depending on
the intended recipient of the released information.
6. Explains that the patient has the right to receive a copy of this authorization. This will be sent to the patient by
Health Information Management.
7. Explains that reasonable fees may be charged to cover copying and postage costs related to releasing the
patient's health information.
Part VIII - “Patient Signature”: The bottom of page two is for the patient's or his/her representative's signature. The
patient's printed name, signature, and date are to be entered in the boxes provided. If this authorization is completed
by a patient representative (e.g., power of attorney, estate representative, next of kin), his/her printed name and
relationship to patient, signature, and date are to be entered in the boxes provided. Also attached must be a copy of
either the Power of Attorney, letters issued in estate proceeding, or declaration of next of kin.
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