Transcription of AUTHORIZATION FOR RELEASE Confidential Patient …
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Example: dental hygienist
AUTHORIZATION FOR RELEASE Confidential Patient …
StateofCalifornia-HealthandHumanServices AgencyDepartmentofHealthCareServicesAUTH ORIZATIONFORRELEASEOFPATIENTINFORMATIONC onfidentialPatientInformationSeeW& :Usethisformtoobtaintherequiredauthoriza tionwhenarequestis receivedforpatientinformation,unlessther equestreceivedisafacsimileofthisformor ,obtain witnesssignature. Listtheinformationreleasedper , ,the patientmayinspectorbeprovidedacopyofthep rotectedhealthinformationtobe sNameBirthDateMonthDayYearI, and/orNameofPatientherebyauthorizeNameof Parent/Guardian/ConservatorNameofAgency/ Person/OrganizationAddress(Street,City,S tateandZipCode)toreleasetoNameofAgency/P erson/OrganizationAddress(Street,City,St ateandZipCode)theinformationspecifiedonP age2ofthisformwiththeknowledgethatsuchre lease 1of 3 DHCS 1811 (06/2013)StateofCalifornia-HealthandHuma nServicesAgency DepartmentofHealthCare ServicesAUTHORIZATIONFORRELEASEOFPATIENT INFORMATIONC onfidentialPatientInformationSeeW& *isrequiredforthefollowingpurpose(s).
Use this form to obtain the required authorization when a request is received for patientinformation,unless the request received is a facsimile of this form or contains all of the required information. Obtain signature of patient or parent/guardian/ ... MH5671, Authorization for Release of Patient Information, HIPAA
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