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 Release Of Health Information
Category:
State:
California
Control #:
CA-JV-226
Format:
PDF
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Description
How to fill out Authorization Release Of Health Information?
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FAQ
The core elements of a valid authorization include: A meaningful description of the information to be disclosed. The name of the individual or the name of the person authorized to make the requested disclosure. The name or other identification of the recipient of the information.
Release of information (ROI) is the process of providing access to protected health information (PHI) to an individual or entity authorized to receive or review it.
Your authorization allows the Health Plan (your health insurance carrier or HMO) to release your protected health information to a person or organization that you choose.
You may disclose the PHI as long as you receive a request in writing. The written request must contain: the covered entity's name, the patient's name, the date of the event/time of treatment, and the reason for the request.
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.
More info
Please download, complete and sign the form and send to Health Information Management (HIM). Please clearly and legibly print all information when completing this form and sign on the last page.Authorization for Disclosure of Health Information. The Release of Authorization form has five sections; please review the instructions for each section prior to completing the form.