Fillable CONFIDENTIAL AUTHORIZATION FOR USE AND DISCLOSURE OF PERSONAL (California)

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CONFIDENTIAL AUTHORIZATION FOR USE AND DISCLOSURE OF PERSONAL (California)

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STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
PRIVACY OFFICE
CONFIDENTIAL
AUTHORIZATION FOR USE AND DISCLOSURE OF PERSONAL INFORMATION
[T
his document must be printed in 14-point type-face, pursuant to State Law]
I,
, hereby authorize
to
(Name of Individual)
(Name of person/facility which has the information)
release the following personal information:
To:
(Name and title or facility name to receive personal information)
(Street address, city, state, zip code)
(Telephone number)
(Fax number)
For the following purposes:
This authorization is in effect until (date or event), when it expires.
• I authorize the use or disclosure of my individually identifiable personal information as described
above for the purpose listed.
• I have the right to withdraw permission for the release of my information. If I sign this
authorization to use or disclose information, I can revoke that authorization at any time except if
you have already acted because of my permission. The revocation must be made in writing and
will not affect information that has already been used or disclosed.
• I have the right to receive a copy of this authorization.
• I am signing this authorization voluntarily and treatment, payment, or my eligibility for benefits will
not be affected if I do not sign this authorization.
•
I further understand that a person to whom records and information are disclosed pursuant to
this authorization may not further use or disclose the personal information unless another
authorization is obtained from me or unless such disclosure is specifically required or permitted
Signed by Individual:
Date
CDPH 6247 (03/18) Page 1 of 3
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signature
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Or Signed by Personal Representative
:
_____________________________________________________
On Behalf of
_____________________________________________________
Name of Individual
Date
IDENTIFYING INFORMATION OF PERSON SIGNING FORM
COPY OF IDENTIFICATION ATTACHED
TYPE
(DRIVER’S LICENSE, DMV IDENTIFICATION
CARD, BIRTH CERTIFICATE, BENEFITS IDENTIFICATION CARD, MANAGED CARE CARD,
STATE OR FEDERAL EMPLOYEE ID CARD)
NUMBER
IF NO IDENTIFICATION IS ATTACHED, YOUR SIGNATURE MUST BE
NOTARIZED
NOTARIZED BY
ON
(DATE)
NOTARY PUBLIC NUMBER
NOT OFFICIAL UNLESS STAMPED BY NOTARY PUBLIC
PERSONAL REPRESENTATIVE INFORMATION
WHAT LEGAL AUTHORITY DO YOU HAVE TO MAKE PERSONAL
DECISIONS FOR THE INDIVIDUAL?
PARENT CONSERVATOR
GUARDIAN EXECUTOR OF WILL
MEDICAL POWER OF ATTORNEY OTHER
NOTE: ATTACHING LEGAL DOCUMENTATION IS REQUIRED TO VERIFY THAT YOU ARE
THE PARENT, CONSERVATOR, GUARDIAN, EXECUTOR OF A DECEDENT’S WILL, OR HAVE
PERSONAL DECISION-MAKING AUTHORITY FOR THE INDIVIDUAL.
CDPH 6247 (03/18) Page 2 of 3
DEPARTMENT EMPLOYEE PROCESSING/MAINTAINING THIS
AUTHORIZATION
(Name and title)
(Organization within Department)
(Telephone number)
(Mail Stop Number)
PRIVACY STATEMENT (CA CIVIL CODE SECTION 1798.17)
THE INFORMATION COLLECTED ON THIS FORM IS USED TO GET YOUR PERMISSION FOR THE USE OR DISCLOSURE, TO NON-
DEPARTMENT PERSONS/ORGANIZATIONS, OF CERTAIN PERSONAL INFORMATION ABOUT YOU MAINTAINED BY THE DEPARTMENT.
THIS INFORMATION WILL BE KEPT CONFIDENTIAL AND ON FILE AT THE CALIFORNIA DEPARTMENT OF PUBLIC HEALTH, AS REQUIRED
BY LAW. ALL INFORMATION REQUESTED ON THE FORM IS VOLUNTARY. NOT SUPPLYING THE INFORMATION REQUESTED WILL HAVE
NO EFFECT ON YOU OR YOUR TREATMENT, PAYMENT, OR ELIGIBILITY FOR BENEFITS OR SERVICES FROM THE CALIFORNIA
DEPARTMENT OF PUBLIC HEALTH. ANY INFORMATION PROVIDED MAY BE DISCLOSED TO THE CALIFORNIA STATE AUDITOR, THE
CALIFORNIA OFFICE OF HEALTH INFORMATION INTEGRITY, THE CALIFORNIA OFFICE OF INFORMATION SECURITY AND PRIVACY
PROTECTION, THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES OR TO OTHER STATE AND FEDERAL AGENCIES AS REQUIRED
BY LAW.
YOU HAVE THE RIGHT TO REVIEW THE RECORDS WE KEEP ABOUT YOU DURING NORMAL BUSINESS HOURS. THE CALIFORNIA
DEPARTMENT OF PUBLIC HEALTH PRIVACY OFFICER WILL, UPON REQUEST, INFORM YOU REGARDING THE LOCATION OF YOUR
RECORDS AND THE CATEGORIES OF ANY PERSONS WHO USE THE INFORMATION IN THOSE RECORDS. FOR MORE INFORMATION,
CONTACT THE CALIFORNIA DEPARTMENT OF PUBLIC HEALTH, PRIVACY OFFICE, USING THE FOLLOWING CONTACT INFORMATION:
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH, OFFICE OF LEGAL SERVICES, PRIVACY OFFICE, 1415 L STREET, SUITE 500
SACRAMENTO, CALIFORNIA 95814 OR BY PHONE 1-877-421-9634.
CDPH 6247 (03/18) Page 3 of 3
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CONFIDENTIAL AUTHORIZATION FOR USE AND DISCLOSURE OF PERSONAL (California)

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Completed 4 March 2021

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