Form DHCS1807 "Authorization for Release of Protected Health Information and Confidential Information" - California

What Is Form DHCS1807?

This is a legal form that was released by the California Department of Health Care Services - 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 June 1, 2013;
  • The latest edition provided by the California Department of Health Care Services;
  • 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 DHCS1807 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form DHCS1807 "Authorization for Release of Protected Health Information and Confidential Information" - California

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State of California - Health and Human Services Agency
Department of Health Care Services
Ombudsman Services Unit
AUTHORIZATION FOR RELEASE
HIPAA Privacy Rule 45 C.F.R.,
OF PROTECTED HEALTH INFORMATION
Section 164.508
AND CONFIDENTIAL INFORMATION
Welfare and Institutions Code,
Section 5328 (c)
_
___
INSTRUCTIONS: Use this form to obtain authorization to disclose protected health
information or other confidential information to third parties when a client is requesting
Ombudsman Services to obtain aid, insurance or medical assistance.
___
___
Client’s Name
Birth Date
______________
Month Day Year
I,
and/or
Name of Client
Name of Parent/Guardian/Conservator
hereby authorize the Department of Mental Health to disclose the following protected health
information or other confidential information:
Diagnosis
Other (specify)
Psychiatric Evaluation Information
______________________________
Social Security Number
______________________________
Address and Telephone Number
______________________________
Date of Birth
______________________________
______
to
Name of Agency/Person/Organization
___
___
Address (Street, City, State and Zip Code)
For the purpose of:
__________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________.
DHCS 1807 (06/2013)
Page 1 of 3
State of California - Health and Human Services Agency
Department of Health Care Services
Ombudsman Services Unit
AUTHORIZATION FOR RELEASE
HIPAA Privacy Rule 45 C.F.R.,
OF PROTECTED HEALTH INFORMATION
Section 164.508
AND CONFIDENTIAL INFORMATION
Welfare and Institutions Code,
Section 5328 (c)
_
___
INSTRUCTIONS: Use this form to obtain authorization to disclose protected health
information or other confidential information to third parties when a client is requesting
Ombudsman Services to obtain aid, insurance or medical assistance.
___
___
Client’s Name
Birth Date
______________
Month Day Year
I,
and/or
Name of Client
Name of Parent/Guardian/Conservator
hereby authorize the Department of Mental Health to disclose the following protected health
information or other confidential information:
Diagnosis
Other (specify)
Psychiatric Evaluation Information
______________________________
Social Security Number
______________________________
Address and Telephone Number
______________________________
Date of Birth
______________________________
______
to
Name of Agency/Person/Organization
___
___
Address (Street, City, State and Zip Code)
For the purpose of:
__________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________.
DHCS 1807 (06/2013)
Page 1 of 3
State of California - Health and Human Services Agency
Department of Health Care Services
Ombudsman Services Unit
AUTHORIZATION FOR RELEASE
HIPAA Privacy Rule 45 C.F.R.,
OF PROTECTED HEALTH INFORMATION
Section 164.508
AND CONFIDENTIAL INFORMATION
Welfare and Institutions Code,
Section 5328 (c)
______________________________________________________________________________________________
By signing this authorization:
• I authorize the use or disclosure of my protected health information and confidential
information as described above for the purpose listed. I understand that this authorization
is voluntary.
• I understand that I have a right to receive a copy of this authorization.
• I understand that I may revoke this authorization at anytime by submitting a signed letter
addressed to the Ombudsman Services Unit, located at 1500 Capitol, Suite 72.220,
Sacramento, CA 95814 stating that I wish to revoke this authorization to release my
protected health information and confidential information. I understand I may email my
signed revocation letter to the Ombudsman Services Unit’s email address at
MHOmbudsman@dhcs.ca.gov.If revoked, the authorization will stop on the date the request
is received or specified in the revocation letter. [45 C.F.R. § 164.508(c)(2)(ii)& Civil Code
§ 56.11(h)] If not revoked, it shall terminate at the end of (check one):
6 months
One year or
Specify Date __________
Date:
Signature of Client
Month
Day
Year
Date:
Signature of Parent/Guardian/Conservator, if Applicable
Month
Day
Year
Date:
DHCS 1807 (06/2013)
Page 2 of 3
State of California - Health and Human Services Agency
Department of Health Care Services
Ombudsman Services Unit
AUTHORIZATION FOR RELEASE
HIPAA Privacy Rule 45 C.F.R.,
OF PROTECTED HEALTH INFORMATION
Section 164.508
AND CONFIDENTIAL INFORMATION
Welfare and Institutions Code,
Section 5328 (c)
_
___
Identifying Information
Copy of Identification Attached
Type __________________________(CA Driver’s License, CA DMV Identification Card,
State or Federal Employee ID Card)
Number ________________________
If No Identification Is Attached, Your Signature Must Be Notarized.
Notarized By ___________________________________________________
On__________________________________(Date)
Notary Public Number ____________________________________________
Unofficial Unless Stamped by Notary Public
DHCS 1807 (06/2013)
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