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Department of Health Care Services (Department of Health Care Services)

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  • 10 check-boxes
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______________________________________________________________________
______________________________________________________________________
State of California—Health and Human Services Agency
Department of Health Care Services
AUTHORIZATION TO DISCLOSE HEALTH INFORMATION
JENNIFER KENT GAVIN NEWSOM
DIRECTOR GOVERNOR
This document authorizes the Department to disclose and discuss health information
about you or the person you represent with the Legislator and the member(s) of his or
her staff assigned to assist with your problem. Unless otherwise indicated below, this
authorization does not authorize the disclosure of HIV information, mental health
treatment information, or alcohol or drug treatment information. Treatment, payment,
enrollment in a health plan, and eligibility for benefits will not be affected if you do not
sign this authorization.
Print Full Name of Beneficiary or Plan Member
OR
_____________________________ on behalf of __________________________________
Print Name of Representative Print Name of Beneficiary or Plan Member
authorizes the Department of Health Care Services to communicate with and disclose medical
information you specify on this form to the office of :
Print Name of Legislator
Briefly describe the problem that led you to contact your Legislator’s Office?
Office of Legislative and Governmental Affairs
MS 0006, PO Box 997413
Sacramento, CA 95899-7413
Phone: (916) 440-7500 ~ FAX: (916) 440-7510
Internet Address: http://www.dhcs.ca.gov/Pages/LGA.aspx
I specifically authorize the release of the following information (check and initial as
appropriate):
□ Mental health treatment information : (initial) ___________
If you check either of the following boxes, you will be required to fill out a different form:
□ HIV information : (initial) ___________
□ Alcohol/drug treatment information : (initial) ___________
This authorization is in effect until the following date ________________________, or the
resolution of the problem described above, after which this authorization expires.
I understand that by signing this authorization:
▲ I authorize the use and disclosure of the health information described on this form only for
the purpose(s) stated.
▲ I have the right to receive a copy of this authorization.
▲ I have the right to revoke this authorization at any time by sending a written notice to the
Department of Health Care Services, Office of Legislative and Governmental Affairs at the
address listed at the bottom of the first page of this authorization.
▲ My revocation is effective upon receipt, except it does not apply to uses and disclosures
before it takes effect.
▲ I understand that health information disclosed through the authorization is no longer
protected and could be disclosed to another entity.
Please fill in the Beneficiary/ Plan Member Information and sign on the next page.
Page | 2
Beneficiary/Plan Member Information
Last Name First Name Middle Initial
Address City/State Zip Code
Benefits Id Number Email Address
Date Of Birth Date Of Death Home Phone Number Work Phone Number
If you are the Representative of a Beneficiary or Plan Member, please fill in your
information and provide a copy of the written legal authority showing that you are
authorized to act on behalf of the beneficiary or plan member. If the plan member or
beneficiary is deceased, please provide a copy of the death certificate.
____________________________________ _____________________________
Printed Name Relationship to Beneficiary
____________________________________ _____________________________
Address E-mail
____________________________________ _____________________________
City, State, Zip Code Telephone Number
Indicate Your Relationship – Please Attach Written Legal Authority
☐
PARENT OF MINOR CHILD
☐
ATTORNEY AT LAW
☐
GUARDIAN
☐
CONSERVATOR
☐
EXECUTOR/ADMINISTRATOR
☐
HEATHCARE POWER OF ATTORNEY
☐
OTHER: ________________________
Please sign the authorization.
I DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION ON THIS FORM IS TRUE
AND CORRECT.
SIGNATURE _____________________________________ DATE ______________________
Page | 3
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Completed 30 July 2020

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