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 4/7/20202
AUTHORIZATION FOR WRC TO RELEASE
CONFIDENTIAL HEALTH INFORMATION
SEE CALIFORNIA WELFARE & INSTITUTIONS CODE, 4514
DISCLOSURE BY WESTSIDE REGIONAL CENTER
By signing this form, I authorize Westside Regional Center to use and disclose my confidential information
to the entity listed below. The information released may contain protected health information that,
consistent with regulation, may be released to public or private entities for the purpose of treatment,
payment, or health care operations. This includes planning for education, training, or other programs for
individuals with developmental disabilities as lawfully required, or as I may authorize.
Entity receiving information: [45 C.F.R. § 164.508(c)(ii) & Civil Code § 56.11 (c)]
Any exceptions are specifically listed:
I have the right to request Westside Regional Center to restrict how they use and disclose my confidential
information, which may contain protected health information. Westside Regional Center is not required by
law to grant my request. However, if Westside Regional Center does decide to grant my request, Westside
Regional Center is bound by our agreement.
This authorization shall remain in effect for one year from the date listed below or until I revoke it. I
understand that I may revoke this authorization at any time by notifying Westside Regional Center 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 required or
permitted by law.
I agree a copy of this form shall be as valid as the original. A copy of this authorization will be provided to
me upon my request.
Legally Authorized Signature
This authoriz
ation will expire on:
[45 C.F.R.§ 164.508(c)(v) & Civ. Code §56.11(h)]
Consumer (if 18 years of age or older)
Parent (if consumer is under 18 years of age)
Representative (Ward of the Court)
Guardian (if under 18 years of age)
Conservator (If over 18 years of age)
Person Releasing Information:
