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
AUTHORIZATION FOR WRC TO OBTAIN CONFIDENTIAL HEALTH INFORMATION
SEE CALIFORNIA WELFARE & INSTITUTIONS CODE, 4514
RELEASE TO WESTSIDE REGIONAL CENTER
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)]
Organization/Person:
Address:
Phone Number:
Fax Number:
Information about:
Name:
Date of Birth:
UCI Number:
Service Coordinator:
Date of Request:
Information Requested for a Hospital Stay:
Discharge Summary
Laboratory Reports
Emergency Medicine Reports
Consultations/Evaluations
Operative Reports
Radiology and Diagnostic Reports
Progress Notes
Other
Information Requested for a Person NOT in a Hospital:
Outpatient Clinic Records
Lab Reports
Consultation/Evaluation Notes
Other
From:
To:
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:
Month/day/year
[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 years of age*)
☐Conservator Court appointed for this adult (over 18 years of age)*
☐Other: Click here to enter text.
*Must attach court documents
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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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