This “Authorization for Use or Disclosure of Protected Health Information to Family Members and
Friends Involved in Member Careform helps CalOptima protect your privacy. We are asking you to
complete this form to let us know you want us to release your protected health information. Please
read the information on this page and complete the form on the next page.
If you have questions or need help completing this form, call CalOptima’s Customer Service
Department at 1-714-246-8500 or toll-free at 1-800-587-8088, Monday through Friday from 8 a.m. to
5:30 p.m. Members with hearing or speech impairments can call our TDD line at 1-800-735-2929.We
have staff who speak your language.
Member Rights
I understand that I must receive a copy of this Authorization.
I understand that I may ask to receive additional copies of this Authorization.
I understand that I may refuse to sign this Authorization.
I understand that I may cancel this Authorization at any time.
I understand that neither treatment nor payment will be dependent upon my refusing or
agreeing to sign this Authorization.
Right to Cancel
I understand that I have the right to cancel this Authorization at any time. To cancel this
Authorization, I understand that I must make my request in writing and clearly state that I am
cancelling this specific Authorization. In addition, I must sign my request and then mail, deliver in
person or fax my request to:
Customer Service Department
505 City Parkway West
Orange, CA 92868
Fax: 1-714-338-3104
I understand that canceling this Authorization will not affect the ability of CalOptima or any health
care provider to use or disclose the protected health information to the extent that it has relied on this
I understand that health information used or disclosed as a result of my signing this Authorization may
not be further used or disclosed by the recipient unless another authorization is obtained from me or
unless such use or disclosure is specifically permitted or required by law.
Rev. 04/2014
Please complete and return to CalOptima
Part A: Member Information
Last Name: ____________________________ First Name: __________________________
CalOptima ID # (CIN): ___________________ Date of Birth:_________________________
Address: _____________________________________________________________________
City: _________________________________ Zip: ________________________________
Phone (Home): _________________________ Phone (Cell): _________________________
Preferred Language: _____________________
Part B: Authorization
Please check the appropriate box below to authorize CalOptima to use or disclose your protected health
information. CalOptima may use or disclosure:
All of my protected health information, OR
Limit the use or disclosure of information to the following:
Part C: Person(s) to Receive Information Listed in Part B
Please print the name of the person(s) authorized to obtain your protected health information. Person(s) listed
below must be over 18 years of age.
Part D: Purpose of the Authorization
To use or disclose the information, at my request, OR
For the following specific purpose: ____________________________________________________
Part E: Expiration Date
This Authorization shall become effective immediately and will end on: _________________________
or three years from the date of signature, whichever is earlier.
Date or Event
Part F: Signature
Signature of Member: _________________________________________ Date: __________________
Signature of Parent or Legal Guardian: ___________________________ Date: __________________
Basis for legal authority to sign this Authorization by a Personal Representative
(If a personal representative has signed this form on behalf of the member, a copy of the Health Care Power of
Attorney, a court order (such as appointment as a conservator, or as the executor or administrator of a deceased
member’s estate),
a Designated Consent from a Regional Center Director or designee (pursuant to
Welfare and Institutions Code Section 4655), or other legal documentation showing the authority of the
personal representative to act on the individual’s behalf must be attached to this form.)
Name of Personal Representative: ___________________________________________________
Legal Relationship to Member: ___________________________________________________
Signature of Personal Representative: ___________________________________________________
Date: ___________________________________________________
Rev. 04/2014