MCAL MM-18-24_DHCS Approved 10.18.18_Authorization for Release of PHI 03/2019
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SECTION D: Person(s) or Agency Allowed to Get PHI
I allow CalOptima to release my PHI to the person or agency below. I know this
authorization starts when I sign and return this form. The person getting the information
must be 18 years of age or older.
Person /Agency’s Name(s):
Relationship to Member: Phone:
SECTION E: My Rights
• I may stop this authorization at any time by sending a written notice to: CalOptima,
Attn: Enrollment & Reconciliation, 505 City Parkway West, Orange, CA 92868.
• Notice to stop this authorization will not change how CalOptima used or released my
PHI before getting my letter.
• The person or agency who gets my PHI from CalOptima may show it to others. In this
case, my PHI may no longer be protected by HIPAA Privacy Rules.
• I do not have to fill out this form. Not filling out this form will not change my health
care benefits or payment for my health care services.
• I have the right to look at or get a copy of my PHI that is being used or released by
• I have the right to get a copy of this form.
SECTION F: End Date of Approval
This authorization for release of information to the named persons or agency will end on:
_______________ (specific date or event).
**If an end date or event is not provided, the authorization will not be valid. **
SECTION G: Signature
I understand that to process my request, a copy of valid government-issued
identification (ID), a copy of documentation of legal authority, or a notarized
signature must be attached with my request form.
By signing below, I have read this form and know what it means.
Signature of Member/Personal Representative
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