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Health Information Manager
15-20 minutes

California HIPAA Authorization for Release of Medical Records Form

The s10.ai HIPAA Medical Records Release Form (California) is an essential tool for healthcare professionals and medical record administrators, facilitating the authorized release of protected health information. Tailored for compliance with both state and federal privacy laws, this template includes comprehensive sections for patient details, authorized entities, specific records to be disclosed, and the intended purpose of the release. It is indispensable for legal, healthcare, or personal use, ensuring that all necessary permissions are documented with precision and clarity. Implementing this template streamlines the medical records release process while upholding HIPAA compliance, making it a vital resource for healthcare providers in California.

2,368 uses
4.3/5.0
J
Jordan Whitaker
Template Structure

Organized sections for comprehensive clinical documentation

State of California
CONSENT FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION
All sections must be completed for the consent to be valid. Use N/A if not applicable.
Part I - Patient Information
Last Name: [insert patient's last name] (enter full legal surname exactly as provided; leave blank if not mentioned)
First Name: [insert patient's first name] (enter full legal first name exactly as provided; leave blank if not mentioned)
Middle Name: [insert patient's middle name] (enter full legal middle name if provided)
Medical Reference Nº: [insert patient's medical record number] (include only if specifically mentioned)
Date of Birth: [insert patient's date of birth] (use full date format; include only if explicitly stated)
Address: [insert full street address of patient] (write full line address; include only if mentioned)
City/State/ZIP: [insert patient's city, state and zip code] (enter all elements of the location; only include if provided)
Part II - Individual/Organization Authorized to Release PHI
Name: [insert full name of the individual or organization authorized to release information] (include only if specified)
Address: [insert street address of releasing party] (write full line address; include only if explicitly mentioned)
City/State/ZIP: [insert city, state, and zip of releasing party] (include in the same line format as the original)
Part III - Individual/Organization Authorized by Signatory to Receive PHI
Name: [insert full name of receiving individual or organization] (only include if mentioned)
Relationship to Patient: [insert relationship of the receiving party to the patient] (e.g. spouse, attorney, etc.; include only if stated)
Phone: [insert phone number of the recipient] (include full number if provided)
Address: [insert recipient's address] (enter street address, city, state, and ZIP on one line as per original)
Part IV - Authorization Expiration Event or Date
Expiration Event: [insert the specific event that will terminate the authorization] (enter as a short description; only include if specified)
Expiration Date: [insert date this authorization expires] (include in standard date format if provided; otherwise leave blank)
Part V - Health Records to be Released - General
I authorized the following records to be released:
[insert general record types to be released] (write out the types of general records selected — e.g., medical, dental, or other — in line format; include only those explicitly mentioned. If 'Other' is selected, specify the content.)
If Other, please specify: [insert custom type of health record] (only include if 'Other' is selected and specified)
Part VI - Health Records to be Released - Specific
[insert list of specific health record types to be released, along with corresponding signatures and dates] (list each selected category individually, using one line per item as follows: category name – Signature: [insert signature] Date: [insert date]. Only include categories mentioned and ensure signature and date are only included if documented.)
Requests for psychotherapy notes require a separate authorization and may not be combined with any other request for health records.
Part VII - Purpose for the Release or Use of the Information
[insert selected purpose for release] (write out the stated reason: e.g. health care, legal, personal, or custom; use a single sentence format. If 'Other' is selected, include the specific reason provided.)
Part VIII - Authorization Information
I understand the following:
1. I authorize the use or disclosure of the health information as described above for the purpose listed. I understand this authorization is voluntary.
2. I have the right to revoke this authorization. To do so I understand I must submit my revocation in writing to the party entered in Part II. The revocation will prevent further release of my health information from the date of receipt.
3. I am signing this authorization voluntarily and understand my health care treatment will not be affected if I do not sign this authorization.
4. The party entered in Part III is prohibited from re-disclosing the health information except with a written authorization or as specifically permitted by Cal. Code §56.10 or required by law (applies within California only).
5. If the party entered in Part III is not a HIPAA Covered Entity or Business Associate as defined in 45 CFR §160.103, the released health information may no longer be protected by federal and state privacy regulations.
6. I have a right to receive a copy of this authorization.
7. Fees may be charged to cover the cost of releasing the health information.
8. I understand that my substance abuse disorder records are protected under the federal regulations governing the Confidentiality of Substance Use Disorder Patient Records and cannot be redisclosed without my written authorization.
Part IX - Signature by or on Behalf of Patient
Name of Patient (Print): [insert patient's full name] (include only if explicitly mentioned; print format)
Signature: [insert patient's signature] (include only if documented)
Date: [insert signature date] (write full date format if provided)
Name of person signing form if not patient: [insert name of proxy signer] (only include if the form was signed by someone else on behalf of the patient)
Authority to sign on behalf of patient: [insert legal basis for proxy] (briefly describe the signer’s legal authority, e.g. legal guardian, power of attorney; include only if specified)
Name of translator (if applicable): [insert translator's name] (only include if interpreter was involved)
Signature of translator (if applicable): [insert translator's signature] (include only if provided)
(Never come up with your own patient details, authorization purposes, records categories, or legal justification – use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Maintain all formatting and paragraph structure exactly as per the source document.)
Sample Clinical Note

Example of completed documentation using this template

State of California
AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION
All sections must be completed for the authorization to be valid. Use N/A if not applicable.
Part I - Patient Information  
Last Name: Smith  
First Name: John  
Middle Name: A.  
Medical Reference Nº: 123456789  
Date of Birth: 15 March 1980  
Address: 123 Main Street  
City/State/ZIP: Los Angeles, CA 90001
Part II - Individual/Organization Authorized to Release PHI  
Name: Dr. Thomas Kelly  
Address: 456 Health Ave  
City/State/ZIP: Los Angeles, CA 90002
Part III - Individual/Organization Authorized by Signatory to Receive PHI  
Name: Jane Doe  
Relationship to Patient: Attorney  
Phone: (555) 123-4567  
Address: 789 Legal Blvd, Los Angeles, CA 90003
Part IV - Authorization Expiration Event or Date  
Expiration Event: Conclusion of legal proceedings  
Expiration Date: 1 November 2025
Part V - Health Records to be Released - General  
I authorized the following records to be released:  
Medical, Dental
Part VI - Health Records to be Released - Specific  
Blood Test Results – Signature: John Smith Date: 1 November 2024  
X-Ray Reports – Signature: John Smith Date: 1 November 2024
Part VII - Purpose for the Release or Use of the Information  
Legal proceedings
Part VIII - Authorization Information  
I understand the following:  
1. I authorize the use or disclosure of the health information as described above for the purpose listed. I understand this authorization is voluntary.  
2. I have the right to revoke this authorization. To do so I understand I must submit my revocation in writing to the party entered in Part II. The revocation will prevent further release of my health information from the date of receipt.  
3. I am signing this authorization voluntarily and understand my health care treatment will not be affected if I do not sign this authorization.  
4. The party entered in Part III is prohibited from re-disclosing the health information except with a written authorization or as specifically permitted by s10.ai Code §56.10 or required by law (applies within California only).  
5. If the party entered in Part III is not a HIPAA Covered Entity or Business Associate as defined in 45 CFR §160.103, the released health information may no longer be protected by federal and state privacy regulations.  
6. I have a right to receive a copy of this authorization.  
7. Fees may be charged to cover the cost of releasing the health information.  
8. I understand that my substance abuse disorder records are protected under the federal regulations governing the Confidentiality of Substance Use Disorder Patient Records and cannot be redisclosed without my written authorization.
Part IX - Signature by or on Behalf of Patient  
Name of Patient (Print): John A. Smith  
Signature: John A. Smith  
Date: 1 November 2024
Clinical Benefits

Key advantages of using this template in clinical practice

  • The "State of California Authorization for the Release of Protected Health Information" template is an essential tool for healthcare providers and organizations seeking to streamline the process of obtaining patient consent for the disclosure of health information. This comprehensive template ensures compliance with state and federal privacy regulations, including HIPAA, by meticulously capturing all necessary patient details, authorized parties, and specific health records to be released. By adopting this template, clinicians can enhance their practice's efficiency, reduce administrative burdens, and ensure that all legal requirements are met for the secure and authorized sharing of patient information. Explore this template to facilitate seamless communication and trust between healthcare providers and patients, while safeguarding sensitive health data.
Frequently Asked Questions

Common questions about this template and its usage

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California HIPAA Authorization for Release of Medical Records Form