Fillable AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (PHI) (CalOptima)

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AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (PHI) (CalOptima)

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The AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (PHI) (CalOptima) form is 3 pages long and contains:

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  • 13 check-boxes
  • 24 other fields

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File type: PDF

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MCAL MM-18-24_DHCS Approved 10.18.18_Authorization for Release of PHI 03/2019
Page 1 of 3
AUTHORIZATION FOR RELEASE OF
PROTECTED HEALTH INFORMATION (PHI)
Fill out ALL sections of this form to allow CalOptima to release your protected health
information (PHI) to another person or agency. This form is ONLY to release the
information. It will not allow anyone to make health care decisions for you.
SECTION A: Member Information
Last Name: First Name:
CIN: Date of Birth:
Address:
mm/dd/yyyy
Street/Unit Number
City
State
Zip Code
Best phone number to contact you:
Instructions: Mark X inside the box next to your selected option.
SECTION B: Information That Can Be Released
I allow CalOptima to release:
Any and all of my PHI
Only release the following: (list what you allow):
I allow the release of PHI about: (Initial if any of the below boxes are checked)
Mental health treatment
Alcohol / drug treatment
Initial:_______
Initial:_______
NOTE: These details will not be released unless you approve first.
SECTION C: Purpose of Authorization
I am releasing this information for:
Personal Use Legal
Insurance Other (please specify.):
MCAL MM-18-24_DHCS Approved 10.18.18_Authorization for Release of PHI 03/2019
Page 2 of 3
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
this authorization.
• 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
Date
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MCAL MM-18-24_DHCS Approved 10.18.18_Authorization for Release of PHI 03/2019
Page 3 of 3
Please mail this form to CalOptima, Attn: Enrollment & Reconciliation, 505 City Parkway
West, Orange CA 92868, or fax it to 1-714-338-3104.
STOP
For CalOptima Use Only:
Staff Name: How was identity verified? In person/Phone
Signature:
Date verified:
Parent/Guardian Signature: Date:
Parent/Guardian Printed Name: Relationship:
CalOptima reserves the right to request legal documentation (e.g., birth certificate, court
order, etc.) from the parent/guardian signing on behalf of a dependent member.
Personal Representatives Only: What rights do you have to request health information?
Print Name:
Conservator
Executor of Will
Administrator of Estate
Medical Power of Attorney
Other______________________________________________________
Note: You must attach legal documentation to verify that you are the conservator,
executor of a decedent’s will, or have medical decision-making authority for the
individual.
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AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (PHI) (CalOptima)

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Completed 11 March 2021

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