An Administrator's Guide to California Private School Law Compendium

This authorization for release of the above information to the above named persons/organizations will expire on:

(date). [45 C.F.R. 164.508(c)(v) & Civ.

Code § 56.11(h)] I understand:

I authorize the use or disclosure of my individually identifiable health information as described above for the purpose listed. I understand that this authorization is voluntary. [45 CFR § 164.508(c)(2)(i)]

 I have the right to revoke this authorization by sending a notice stopping this authorization to_________________ at_________________. The authorization will stop on the date my request is received. [45 C.F.R. § 164.508(c)(2)(ii)& Civ. Code § 56.11(h)]  I understand the Notice of Privacy Practices provides instructions should I choose to revoke my authorization. [45 C.F.R. § 164.508(c)(ii)]  I understand that I cannot revoke ________________________. (Covered entities must select one of the following: 1) this authorization because the covered entity has taken action in reliance on the authorization, or 2) the authorization because it was obtained as a condition of obtaining insurance coverage) [45 C.F.R. § 164.508(c)(2)(i)]  I understand that I am signing this authorization voluntarily and that treatment, payment or eligibility for my benefits will not be affected if I do not sign this authorization. [45 C.F.R. § 164.508(c)(2)(ii)]  I understand that I am signing this authorization voluntarily and that treatment, payment or eligibility for my benefits will be affected if I do not sign this authorization. The consequences for my refusal to sign this authorization will be______________________. (The covered entity must state the consequences if the individual’s treatment, enrollment in a health plan or eligibility for benefits if conditioned on the individual’s signing the authorization.) [45 C.F.R. § 164.508(c)(2)(ii)]  I understand if the organization I have authorized to receive the information is not a health plan or health-care provider, the released information may no longer be protected by federal privacy regulations. [45 C.F.R. § 164.508(c)(2)(iii)]  I understand I have the right to receive a copy of this authorization. (Civ. Code §56.12)

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Covered Entity’s Optional Statements

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Covered Entity’s Optional Statements

Signature:

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