STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF HEALTH CARE SERVICES
PRIVACY OFFICE
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
I,
(Name of patient)
, hereby authorize
(Name of person or facility which has information)
to
release the following health information:
To:
(Name and title or facility name to receive health information)
(Street address, city, state, ZIP code) (Telephone number) (Fax number)
For the following purposes:
This authorization is in effect until (date or event), when it expires.
I understand that by signing this authorization:
• I authorize the use or disclosure of my individually identifiable health information as
described above for the purpose listed.
• I have the right to withdraw permission for the release of my information. If I sign this
authorization to use or disclose information, I can revoke that authorization at any time.
The revocation must be made in writing and will not affect information that has already
been used or disclosed.
• I have the right to receive a copy of this authorization.
• I am signing this authorization voluntarily and treatment, payment, or my eligibility for
benefits will not be affected if I do not sign this authorization.
• I further understand that a person to whom records and information are disclosed pursuant
to this authorization may not further use or disclose the medical information unless another
authorization is obtained from me or unless such disclosure is specifically required or
permitted by law.
Signed by Patient:Signed by Patient: Date
Or Signed by Personal Representative:
_____________________________________________________
On Behalf of
_____________________________________________________
Name of Patient
Date
DHCS 6247 (11/07) Page 1 of 2
