An Administrator's Guide to California Private School Law Compendium
C HAPTER 10 – P RIVACY R IGHTS O F S TUDENTS A ND E MPLOYEES D OCUMENT 10.A
HIPAA P RIVACY A UTHORIZATION F OR R ELEASE O F I NFORMATION YOUR INFORMATION Last Name: First Name:
Middle Initial:
Address:
City/State:
Zip Code:
Person/Organization Providing the Information [45 C.F.R.§ 164.508(c)(ii) & Civ. Code § 56.11(c)]
Person/Organization to Receive the Information [45 C.F.R.§ 164.508(c)(iii) & Civ. Code § 56.11(f)]
Description of the Information to be Released (Provide a detailed description of the specific information to be released) [45 C.F.R. § 164.508(c)(i)& Civ. Code § 56.11(d) & (g)]]
Description of Each Purpose for the Use or Release of the Information (Provide a detailed description of the activity for which the information will be used) [45 C.F.R. § 164.508(c)(iv)]
Will the health plan or provider receive money for the release of this information? [45 C.F.R. § 164.508(a)(3)] Yes No
An Administrator’s Guide to California Private School Law - Compendium ©2019 Liebert Cassidy Whitmore 153
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