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.