Fillable AUTHORIZATION FOR WRC TO OBTAIN CONFIDENTIAL HEALTH INFORMATION (Westside Regional Center)

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AUTHORIZATION FOR WRC TO OBTAIN CONFIDENTIAL HEALTH INFORMATION (Westside Regional Center)

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Committed to providing Support and Services to People with Developmental Disabilities
5901 Green Valley Circle, Suite 320, Culver city, CA 90230-6953 ■ (310) 258-4000 FAX: (310) 649-1024
www.westsiderc.org
Revised 4/7/2020
Page 1 of 1
AUTHORIZATION FOR WRC TO OBTAIN
CONFIDENTIAL HEALTH INFORMATION
FAX
Service Coordinator Email
MAIL TO
5901 Green Valley Circle
Suite 320
Culver City CA 90230
RELEASE TO WESTSIDE REGIONAL CENTER (SEE CALIFORNIA WELFARE & INSTITUTIONS CODE, 4514)
I hereby authorize the entity or provider listed below to release to Westside Regional Center my confidential information
which may contain protected health information including any medical, psychiatric, psychological, mental health, social, legal,
drug and/or alcohol abuse, educational, speech or therapy information for inclusion in their records for the purposes of
assessment, consultation, case management, service authorization, treatment, payment and health care operations, including
determining eligibility and planning for services and benefits for individuals with developmental disabilities. I understand that
my refusal to sign this form, or any exceptions I make to the release of my confidential information, will not affect decisions
about services I receive from Westside Regional Center, except to the extent that lack of information may prevent a thorough
assessment in the determination of eligibility for their services.
Entity providing information: [45 C.F.R.§ 164.508(c)(ii) & Civ. Code § 56.11 (c)]
PERSON/ORGANIZATION:
ADDRESS:
PH:
CITY, STATE, ZIPCODE:
FAX:
Date(s) of Service: From: ____To: ____
Information Requested:
Laboratory Reports
Emergency Medicine Reports
Operative Reports
Radiology and Diagnostic Reports
Progress Notes
Drug & Alcohol Abuse Information
Dental Records
Psychological/Vocational Test Results
EKG
Other
This authorization shall remain in effect for one year from the date signed below or until I revoke it. I understand that I may
only revoke this authorization by notifying my Westside Regional Center Service Coordinator in writing. My revocation will not
affect actions taken by Westside Regional Center prior to its receipt.
I understand that federal law does not protect health information if it is disclosed to someone other than another health care
provider, health plan, or health care clearinghouse. However, under California law all recipients of health care information are
prohibited from re-disclosing it except as specially directed by the patient or as required or permitted by law. I agree that a
copy of this form shall be as valid as the original and that a copy of this authorization will be provided to me upon my request.
Consumer or Legally Authorized Signature*:
Date
Witness (if required)
Date
This authorization expires:
/ /
[45 C.F.R.§ 164.508(c)(v) & Civ. Code §56.11(h)]
*LEGAL STATUS OF PERSON SIGNING DOCUMENT
Consumer (if 18 yrs. of age or older)
Parent (if child is under 18 years of age)
Representative appointed for this Ward of the Court *
Guardian Court appointed if child is under 18 yrs*
Conservator Court appointed for this adult (over 18)*
Other:
*Must attach court documents
Name:
Date of Birth:
/ /
UCI Number:
Service Coordinator:
Date Of Request:
/ /
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AUTHORIZATION FOR WRC TO OBTAIN CONFIDENTIAL HEALTH INFORMATION (Westside Regional Center)

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Completed 7 February 2021

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