This form is an official California Judicial Council form which complies with all applicable state codes and statutes. USLF updates all state forms as is required by state statutes and law.
Authorization For Release Of Health Records
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State:
California
Control #:
CA-JV-226
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PDF
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Valid HIPAA Authorizations: A ChecklistNo Compound Authorizations. The authorization may not be combined with any other document such as a consent for treatment.Core Elements.Required Statements.Marketing or Sale of PHI.Completed in Full.Written in Plain Language.Give the Patient a Copy.Retain the Authorization.
Generally, only a patient can authorize the release of his or her own medical records. However, there are some exceptions to the rule and generally the following can sign a release: Parents of minor children. Legal guardian.
Generally, an authorization provides the authority for a doctor's release of PHI for specified purposes, which are generally other than treatment, payment, or healthcare operations, or, to disclose protected health information to a third party specified by the individual.
The physician should ask the patient to sign a written authorization to release this nontherapeutic information. The written permission should be dated, state to whom the information is to be released, which information may be passed on to that party, and when the permission to obtain information expires.
An authorization is a detailed document that gives covered entities permission to use protected health information for specified purposes, which are generally other than treatment, payment, or health care operations, or to disclose protected health information to a third party specified by the individual.
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Authorization on behalf of Patient (Please complete page 2 of form). Print clearly; each section needs to be completed to be valid. 2.Additional Patient Information. Carolinas HealthCare System. Instructions for Completing the Authorization for Release of Health Information.