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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