Form GC-336 Ex Parte Order Authorizing Disclosure of (Proposed) Conservatee's Health Information to Court Investigator - Hipaa - California

Form GC-336 is a California Superior Court form also known as the "Ex Parte Order Authorizing Disclosure Of (proposed) Conservatee's Health Information To Court Investigator - Hipaa". The latest edition of the form was released in January 1, 2009 and is available for digital filing.

Download an up-to-date Form GC-336 in PDF-format down below or look it up on the California Superior Court Forms website.

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GC-336
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
FOR COURT USE ONLY
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
CONSERVATORSHIP OF THE
PERSON
ESTATE
OF
(Name):
(PROPOSED) CONSERVATEE
EX PARTE ORDER AUTHORIZING DISCLOSURE OF
CASE NUMBER:
(PROPOSED) CONSERVATEE'S HEALTH INFORMATION
TO COURT INVESTIGATOR—HIPAA
(Health Insurance Portability and Accountability Act of 1996)
THE COURT FINDS
A conservatorship proceeding under the Guardianship—Conservatorship Law (Parts 1–4 of Division 4 of the Probate Code, section
1.
1400 et seq.) is pending in this court for the person named in the caption above as the (proposed) conservatee.
2. To perform the investigations required by law, the court investigator or investigators named in item 3 must have access to protected
health information about the (proposed) conservatee named in the caption above.
3.
The court investigators authorized to access the (proposed) conservatee's protected health information are (name each authorized
court investigator):
THE COURT ORDERS
4.
Notice is dispensed with.
5.
Each health-care provider, health plan, and health-care clearinghouse that has protected health-care information about the
(proposed) conservatee named above is authorized to disclose the information to any court investigator named in item 3.
6.
The protected health information must be used by the court investigator solely to discharge the investigator's responsibilities in this
proceeding and is governed by the disclosure safeguards contained in the regulations of the federal Department of Health and
Human Services (45 C.F.R. §§ 160 and 164) under the Health Insurance Portability and Accountability Act of 1996 (Pub.L. No.
104-191 (August 21, 1996)). No use of the protected health information other than that which is permitted in those regulations is
permitted by this order.
7.
Additional orders, the judicial officer's signature, and the date of this order are on the next page.
Date:
Judicial Officer
(Clerk's certification is on the next page.)
Page 1 of 2
Form Adopted for Mandatory Use
EX PARTE ORDER AUTHORIZING DISCLOSURE OF
Civil Code, § 56.10;
Judicial Council of California
Probate Code, §§ 1801, 1821, 1826;
(PROPOSED) CONSERVATEE'S HEALTH INFORMATION
GC-336 [New January 1, 2009]
42 U.S.C. §§ 1177, 1178;
45 C.F.R. §§ 160 and 164
TO COURT INVESTIGATOR—HIPAA
www.courtinfo.ca.gov
(Probate—Guardianships and Conservatorships)
GC-336
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
FOR COURT USE ONLY
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
CONSERVATORSHIP OF THE
PERSON
ESTATE
OF
(Name):
(PROPOSED) CONSERVATEE
EX PARTE ORDER AUTHORIZING DISCLOSURE OF
CASE NUMBER:
(PROPOSED) CONSERVATEE'S HEALTH INFORMATION
TO COURT INVESTIGATOR—HIPAA
(Health Insurance Portability and Accountability Act of 1996)
THE COURT FINDS
A conservatorship proceeding under the Guardianship—Conservatorship Law (Parts 1–4 of Division 4 of the Probate Code, section
1.
1400 et seq.) is pending in this court for the person named in the caption above as the (proposed) conservatee.
2. To perform the investigations required by law, the court investigator or investigators named in item 3 must have access to protected
health information about the (proposed) conservatee named in the caption above.
3.
The court investigators authorized to access the (proposed) conservatee's protected health information are (name each authorized
court investigator):
THE COURT ORDERS
4.
Notice is dispensed with.
5.
Each health-care provider, health plan, and health-care clearinghouse that has protected health-care information about the
(proposed) conservatee named above is authorized to disclose the information to any court investigator named in item 3.
6.
The protected health information must be used by the court investigator solely to discharge the investigator's responsibilities in this
proceeding and is governed by the disclosure safeguards contained in the regulations of the federal Department of Health and
Human Services (45 C.F.R. §§ 160 and 164) under the Health Insurance Portability and Accountability Act of 1996 (Pub.L. No.
104-191 (August 21, 1996)). No use of the protected health information other than that which is permitted in those regulations is
permitted by this order.
7.
Additional orders, the judicial officer's signature, and the date of this order are on the next page.
Date:
Judicial Officer
(Clerk's certification is on the next page.)
Page 1 of 2
Form Adopted for Mandatory Use
EX PARTE ORDER AUTHORIZING DISCLOSURE OF
Civil Code, § 56.10;
Judicial Council of California
Probate Code, §§ 1801, 1821, 1826;
(PROPOSED) CONSERVATEE'S HEALTH INFORMATION
GC-336 [New January 1, 2009]
42 U.S.C. §§ 1177, 1178;
45 C.F.R. §§ 160 and 164
TO COURT INVESTIGATOR—HIPAA
www.courtinfo.ca.gov
(Probate—Guardianships and Conservatorships)
GC-336
CONSERVATORSHIP OF (Name):
CASE NUMBER:
(PROPOSED) CONSERVATEE
8.
Additional orders (specify):
,
Date:
Judicial Officer
CERTIFICATION
I certify that this document is a correct copy of the original on file in my office.
Date:
Clerk, by
, Deputy
(SEAL)
GC-336 [New January 1, 2009]
Page 2 of 2
EX PARTE ORDER AUTHORIZING DISCLOSURE OF
(PROPOSED) CONSERVATEE'S HEALTH INFORMATION
TO COURT INVESTIGATOR—HIPAA
(Probate—Guardianships and Conservatorships)
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