Orange County Student Mental Health

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Authorization to Use or Disclose Protected Health Information (PHI)

Source: Orange County Health Care Agency

Resource Type: Template or Tool

Audience(s): City or County Agency Staff, Community Member or Organization, Educators, Families, Health or Mental Health Professional, School Staff or Administrators, Students

Focus Population: BIPOC (Black, Indigenous, or People of Color), Foster Youth, Immigrant or Refugee, LGBTQ, Youth in Military Families, Youth with Disabilities

Topics: Privacy and Confidentiality

Down loadable privacy forms in multiple languages from the Directors Office. This authorization form may be used by you as a patient/client of the County in order to initiate a request to have PHI about you disclosed outside of the Health and Human Services Agency or between Programs with sensitive confidentiality requirements.