Form DHCS 1811 Authorization for Release of Patient Information - California

Form DHCS1811 or the "Authorization For Release Of Patient Information" is a form issued by the California Department of Health Care Services.

Download a PDF version of the Form DHCS1811 down below or find it on the California Department of Health Care Services Forms website.

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State of California - Health and Human Services Agency
Department of Health Care Services
AUTHORIZATION FOR RELEASE
Confidential Patient Information
OF PATIENT INFORMATION
See W&I Code Section 5328 and
HIPAA Privacy Rule CFR Section 164.508
INSTRUCTIONS: Use this form to obtain the required authorization when a request is
received for patient information, unless the request received is a facsimile of this form or
contains all of the required information. Obtain signature of patient or parent/guardian/
conservator. If patient signs, obtain “witness signature.” List the information released per
this authorization on the back of this form.
The hospital shall not condition treatment or payment based on this authorization.
The patient may refuse to sign the authorization. If the authorization is not signed,
the information shall not be released except when required by law. Upon request, the
patient may inspect or be provided a copy of the protected health information to be
disclosed by this authorization.
Patient’s Name
Birth Date
Month Day Year
I,
and/or
Name of Patient
Name of Parent/Guardian/Conservator
hereby authorize
Name of Agency/Person/Organization
Address (Street, City, State and Zip Code)
to release to
Name of Agency/Person/Organization
Address (Street, City, State and Zip Code)
the information specified on Page 2 of this form with the knowledge that such release
discloses the fact that mental health services have been/are being provided.
DHCS 1811 (06/2013)
Page 1 of 3
State of California - Health and Human Services Agency
Department of Health Care Services
AUTHORIZATION FOR RELEASE
Confidential Patient Information
OF PATIENT INFORMATION
See W&I Code Section 5328 and
HIPAA Privacy Rule CFR Section 164.508
INSTRUCTIONS: Use this form to obtain the required authorization when a request is
received for patient information, unless the request received is a facsimile of this form or
contains all of the required information. Obtain signature of patient or parent/guardian/
conservator. If patient signs, obtain “witness signature.” List the information released per
this authorization on the back of this form.
The hospital shall not condition treatment or payment based on this authorization.
The patient may refuse to sign the authorization. If the authorization is not signed,
the information shall not be released except when required by law. Upon request, the
patient may inspect or be provided a copy of the protected health information to be
disclosed by this authorization.
Patient’s Name
Birth Date
Month Day Year
I,
and/or
Name of Patient
Name of Parent/Guardian/Conservator
hereby authorize
Name of Agency/Person/Organization
Address (Street, City, State and Zip Code)
to release to
Name of Agency/Person/Organization
Address (Street, City, State and Zip Code)
the information specified on Page 2 of this form with the knowledge that such release
discloses the fact that mental health services have been/are being provided.
DHCS 1811 (06/2013)
Page 1 of 3
State of California - Health and Human Services Agency
Department of Health Care Services
AUTHORIZATION FOR RELEASE
Confidential Patient Information
OF PATIENT INFORMATION
See W&I Code Section 5328 and
HIPAA Privacy Rule C.F.R. Section 164.508
This disclosure of information* is required for the following purpose(s):
(initial applicable
Evaluation
Treatment Planning/Course
Other (Specify)
areas)
and shall be limited to releasing the following types of information (initial all applicable
areas): from (date required)
to (date required)
;
or any information/records indicated, regardless of date.
Entire Record
Seclusion and/Restraint
Results of Psychological/
Diagnosis
Information
Vocational Testing
Conference(s) Date(s)
Psychiatric Evaluation
HIV Tests Results
Discharge Summary
Other Evaluations/
Social History
Assessments (specify)
Individual Treatment
Plan
Other (specify)
Legal Information
Medical,
Neurological
Assessment,
Lab
Tests,
e.g., EEG, EKG, etc.
*The information disclosure under this authorization may be subject to re-disclosure by the
recipient if allowed or required by law. This authorization becomes effective
(Month/Day/Year)
. This authorization may be revoked in writing by the
undersigned at anytime except to the extent that action has already been taken. If not
revoked, it shall terminate at the end of (check one):
6 months
One year or
Specify Date
.
I understand that I am to receive a copy of this authorization.
Date:
Signature of Patient
Month
Day
Year
Date:
Signature of Parent/Guardian/Conservator, if Applicable
Month
Day
Year
Date:
Witness Signature
Month
Day
Year
Signature of Professional*
Date
Person Obtaining Authorization Date
*Professional for this authorization refers only to a Physician, Licensed Psychologist or
Social Worker with a Master’s degree in social work, or Marriage and Family Therapist who
approves this patient initiated request for release of patient records.
DHCS 1811 (06/2013)
Page 2 of 3
State of California - Health and Human Services Agency
Department of Health Care Services
AUTHORIZATION FOR RELEASE
Confidential Patient Information
OF PATIENT INFORMATION
See W&I Code Section 5328 and
HIPAA Privacy Rule C.F.R. Section 164.508
RECORD OF RELEASE OF INFORMATION
The following information was released to the named party specified on the front of this form.
Identify the specific dates of the reports, records, items released.
Entire Record
Legal Information
Other Evaluations/
Assessments (specify)
Diagnosis
Medical, Neurological
Assessment, Lab
Psychiatric Evaluation
Tests, e.g., EEG,
Discharge Summary
EKG, etc.
Social History
HIV Tests Results
Conference(s) Date(s)
Individual Treatment
Results of Psychological/
Plan
Vocational Testing
Other:
Released By (Name & Title)
Date Released
DHCS 1811 (06/2013)
Page 3 of 3

Download Form DHCS 1811 Authorization for Release of Patient Information - California

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