Form DPR-ENF-133 "Medical Information Authorization" - California

What Is Form DPR-ENF-133?

This is a legal form that was released by the California Department of Pesticide Regulation - 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 July 1, 2013;
  • The latest edition provided by the California Department of Pesticide Regulation;
  • 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 DPR-ENF-133 by clicking the link below or browse more documents and templates provided by the California Department of Pesticide Regulation.

ADVERTISEMENT
ADVERTISEMENT

Download Form DPR-ENF-133 "Medical Information Authorization" - California

117 times
Rate (4.3 / 5) 7 votes
STATE OF CALIFORNIA
DEPARTMENT OF PESTICIDE REGULATION
MEDICAL INFORMATION AUTHORIZATION
ENFORCEMENT BRANCH
DPR-ENF-133 (REV. 07/13)
PAGE 1 OF 1
PHYSICIAN OR HOSPITAL
I hereby authorize
ADDRESS
CITY, STATE AND ZIP CODE
NAME OF RECIPIENT OR RESPONSIBLE AGENCY
to furnish to
ADDRESS
CITY, STATE AND ZIP CODE
medical records, including my date of birth given below, and all information pertinent to medical care,
treatment, hospitalization and/or outpatient care received by
(self,
child, or ward) in regard to (describe incident):
which occurred in
County on (date or dates)
I understand the purpose of providing this information is to assist in the investigation of the above
incident, and for use in any associated legal or administrative action connected with the incident.
I understand that this information will be used by the County Agricultural Commissioner's office in the
above-listed county and by the Department of Pesticide Regulation. Such release will aid in the
investigation of the incident described above.
I understand information disclosed pursuant to this authorization could be re-disclosed by the recipient
and may no longer be protected by federal confidentiality laws (HIPAA).
This authorization expires a year after the date of signature, or as specified
.
Under the Information Practices Act of 1977 (California Civil Code section 1798, et seq.), the requestor
may not disclose the medical information beyond the expiration of the authorization agreed to above
unless another authorization is obtained from me or unless such use or disclosure is specifically required
or permitted by law pursuant to state confidentiality laws.
This authorization may be revoked at any time. My revocation will be effective upon receipt, but will have
no impact on uses or disclosures made while my authorization was valid.
I have received a copy of this authorization.
A photocopy of this authorization may be used the same as the original.
DATE
AUTHORIZING SIGNATURE (MAY BE SIGNED INDIVIDUALLY OR AS PARENT OR GUARDIAN) PATIENT'S DATE OF BIRTH
DATE
WITNESS
DISTRIBUTION:
WHITE - FILE
CANARY - PHYSICIAN OR HOSPITAL
PINK - AUTHORIZING SIGNATURE OR PATIENT
STATE OF CALIFORNIA
DEPARTMENT OF PESTICIDE REGULATION
MEDICAL INFORMATION AUTHORIZATION
ENFORCEMENT BRANCH
DPR-ENF-133 (REV. 07/13)
PAGE 1 OF 1
PHYSICIAN OR HOSPITAL
I hereby authorize
ADDRESS
CITY, STATE AND ZIP CODE
NAME OF RECIPIENT OR RESPONSIBLE AGENCY
to furnish to
ADDRESS
CITY, STATE AND ZIP CODE
medical records, including my date of birth given below, and all information pertinent to medical care,
treatment, hospitalization and/or outpatient care received by
(self,
child, or ward) in regard to (describe incident):
which occurred in
County on (date or dates)
I understand the purpose of providing this information is to assist in the investigation of the above
incident, and for use in any associated legal or administrative action connected with the incident.
I understand that this information will be used by the County Agricultural Commissioner's office in the
above-listed county and by the Department of Pesticide Regulation. Such release will aid in the
investigation of the incident described above.
I understand information disclosed pursuant to this authorization could be re-disclosed by the recipient
and may no longer be protected by federal confidentiality laws (HIPAA).
This authorization expires a year after the date of signature, or as specified
.
Under the Information Practices Act of 1977 (California Civil Code section 1798, et seq.), the requestor
may not disclose the medical information beyond the expiration of the authorization agreed to above
unless another authorization is obtained from me or unless such use or disclosure is specifically required
or permitted by law pursuant to state confidentiality laws.
This authorization may be revoked at any time. My revocation will be effective upon receipt, but will have
no impact on uses or disclosures made while my authorization was valid.
I have received a copy of this authorization.
A photocopy of this authorization may be used the same as the original.
DATE
AUTHORIZING SIGNATURE (MAY BE SIGNED INDIVIDUALLY OR AS PARENT OR GUARDIAN) PATIENT'S DATE OF BIRTH
DATE
WITNESS
DISTRIBUTION:
WHITE - FILE
CANARY - PHYSICIAN OR HOSPITAL
PINK - AUTHORIZING SIGNATURE OR PATIENT