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

Form PERS-BSD-35 is a California Public Employees' Retirement System form also known as the "Authorization To Disclose Protected Health Information". The latest edition of the form was released in November 1, 2011 and is available for digital filing.

Download a fillable PDF version of the Form PERS-BSD-35 down below or find it on California Public Employees' Retirement System Forms website.

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Authorization to Disclose
Protected Health Information
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
Fax: (916) 795-1280
Member Information
Section 1
Name of Member (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
(
)
(
)
Daytime Phone
Evening Phone
Address
City
State
ZIP
I authorize the disclosure of my protected health information, including, but not limited to, 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
physical, mental, psychological or psychiatric condition, to the California Public Employees’ Retirement System
(CalPERS) or its representative, for the sole purposes of determining my physical or mental condition, illness, or
disability and my right, if any, to retirement or reinstatement under the Public Employees’ Retirement Law (PERL)
(Government Code sections 20000, et seq.). I understand that any information about me disclosed pursuant to
this Authorization will be used by CalPERS for the administration of its duties under the PERL, the Social Security
Act, and the Public Employees’ Medical and Hospital Care Act. I understand that submission of the requested
information is mandatory under Government Code section 20128 and that failure to supply the information
requested may result in CalPERS being unable to make a determination regarding my status.
This Authorization applies to any and all health and/or medical related information about me in the possession
of any health care provider, health plan, insurance company or fund, employer or plan administrator, government
agency, organization or entity administering a benefit program, rehabilitation organization or program.
I understand that if my protected health information is disclosed to someone who is not required to comply
with federal privacy protection regulations, that information may be re-disclosed and would no longer
be protected.
I understand that I have a right to revoke this Authorization at any time. My revocation must be in writing by
letter directed to the CalPERS Benefit Services Division at the address below. I am aware that my revocation is
not effective to the extent that persons I have authorized to use and/or disclose my protected health information
have acted in reliance upon this Authorization. Unless cancelled 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.
I understand that I may request a copy of this Authorization at any time.
Authorization to Release Information
Section 2
I also authorize the disclosure of any and all personnel and other employment-related records on file
with any of my present or former employers which relate to my job duties, work performance, and other
work-related issues including, but not limited to, attendance and sick leave records and records of
administrative and judicial action arising out of, or related to, my past or present employment.
Signature of Member
Date (mm/dd/yyyy)
Mail to:
CalPERS Benefit Services Division
P.O. Box 2796, Sacramento, California 95812-2796
PERS-BSD-35 (11/11)
Page 1 of 1
Authorization to Disclose
Protected Health Information
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
Fax: (916) 795-1280
Member Information
Section 1
Name of Member (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
(
)
(
)
Daytime Phone
Evening Phone
Address
City
State
ZIP
I authorize the disclosure of my protected health information, including, but not limited to, 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
physical, mental, psychological or psychiatric condition, to the California Public Employees’ Retirement System
(CalPERS) or its representative, for the sole purposes of determining my physical or mental condition, illness, or
disability and my right, if any, to retirement or reinstatement under the Public Employees’ Retirement Law (PERL)
(Government Code sections 20000, et seq.). I understand that any information about me disclosed pursuant to
this Authorization will be used by CalPERS for the administration of its duties under the PERL, the Social Security
Act, and the Public Employees’ Medical and Hospital Care Act. I understand that submission of the requested
information is mandatory under Government Code section 20128 and that failure to supply the information
requested may result in CalPERS being unable to make a determination regarding my status.
This Authorization applies to any and all health and/or medical related information about me in the possession
of any health care provider, health plan, insurance company or fund, employer or plan administrator, government
agency, organization or entity administering a benefit program, rehabilitation organization or program.
I understand that if my protected health information is disclosed to someone who is not required to comply
with federal privacy protection regulations, that information may be re-disclosed and would no longer
be protected.
I understand that I have a right to revoke this Authorization at any time. My revocation must be in writing by
letter directed to the CalPERS Benefit Services Division at the address below. I am aware that my revocation is
not effective to the extent that persons I have authorized to use and/or disclose my protected health information
have acted in reliance upon this Authorization. Unless cancelled 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.
I understand that I may request a copy of this Authorization at any time.
Authorization to Release Information
Section 2
I also authorize the disclosure of any and all personnel and other employment-related records on file
with any of my present or former employers which relate to my job duties, work performance, and other
work-related issues including, but not limited to, attendance and sick leave records and records of
administrative and judicial action arising out of, or related to, my past or present employment.
Signature of Member
Date (mm/dd/yyyy)
Mail to:
CalPERS Benefit Services Division
P.O. Box 2796, Sacramento, California 95812-2796
PERS-BSD-35 (11/11)
Page 1 of 1
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

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

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