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It collects patient and authorized party details, specifies the authorization expiration event or date, and defines the exact categories of health information to be released (general, specific, and psychotherapy-related notes when applicable). It also states required purposes (healthcare, research, marketing, sale, legal), patient rights to revoke, and conditions limiting further protection under federal and California privacy regulations.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/hipaa-authorization-form-california-patientplan-member-phi-release/195370/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/hipaa-authorization-form-california-patientplan-member-phi-release/195370.png","ImageObject",442,249,{"name":88,"@type":89},"supergirl","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-07","2026-09-03",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information does Section 1 require from the patient or plan member?","Question",{"text":108,"@type":109},"Section 1 collects the patient/plan member’s last name, first name, middle name, reference number, date of birth, and address details including city/state/ZIP.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How is the expiration of the PHI authorization determined?",{"text":113,"@type":109},"Section 4 states the authorization expires on the event or date specified. If the release is ongoing, enter N/A in both fields.",{"name":115,"@type":106,"acceptedAnswer":116},"Can the patient revoke this HIPAA authorization?",{"text":117,"@type":109},"Yes. Section 8 explains the patient has the right to revoke by submitting the revocation in writing to the party listed in Section 2, and it prevents further disclosure from the receipt date.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},195370,1788447944,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":135,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":79,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":125,"read_time":73},962088121634,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","| Section 1 – Patient/Plan Member Information |\n| --- |\n| Last Name:   First Name:   Middle Name:   Reference Nº:   Date of Birth:   Address:   City/State/ZIP:   |\n\n\n| Section 2- Individual/Organization Authorized by Signatory to Disclose PHI |\n| --- |\n| Name:   Address:   City/State/ZIP:   |\n\n\n| Section 3- Individual/Organization Authorized by Signatory to Receive PHI |\n| --- |\n| Name:   Relationship to Patient/Plan Member:  Telephone Nº:   Address:   City/State/ZIP:   |\n\n\n| Section 4-Authorization Expiration Event or Date |\n| --- |\n| Unless otherwise revoked by the patient/plan member, this authorization for the release of PHI to the above-named individual/organization will expire on the event or date specified below. Enter N/A in both fields if the release is ongoing.\u003Cbr>Expiration Event:   Expiration Date:   |\n\n\n| Section 5 – Health Information to be Disclosed-General |\n| --- |\n| I authorize the following Protected Health Information to be disclosed:\u003Cbr>q Medical Records q Dental Records q Other Non-Specific\u003Cbr>If Other Non-Specific, provide details:  |\n\n\n| Section 6 – Health Information to be Disclosed – Specific |\n| --- |\n| I authorize the following Protected Health Information to be disclosed:\u003Cbr>q Communicable Disease Signature:   Date:  \u003Cbr>q Reproductive Health Signature:   Date:  \u003Cbr>q Genetic Test Results Signature:   Date:  \u003Cbr>q HIV Test Results Signature:   Date:  \u003Cbr>q Mental Health Records * Signature:   Date:  \u003Cbr>q Substance Use Disorder Signature:   Date:  \u003Cbr>q Other Signature:   Date:   If \"Other\", provide details:  \u003Cbr>* Requests for psychotherapy notes require a separate HIPAA Authorization Form and may not be combined with any other request .\u003Cbr>q Psychotherapy Notes Signature:   Date:   |\n\n\n| Section 7-Purpose of the Release or Use of Health Information |\n| --- |\n| q Healthcare q Research q Marketing q Sale q Legal\u003Cbr>q Other (please specify):   Note: The sale of PHI authorized by this HIPAA Authorization Form will result in remuneration to the party specified in Section 2. |\n\n\n| Section 8-Authorization Information |\n| --- |\n| I understand the following:\u003Cbr>1. I authorize the use or disclosure of Protected Health Information as described above for the purpose indicated until such event or time as specified in Section 4.\u003Cbr>2. I have the right to revoke this authorization. To do so I understand I must submit my revocation in writing to the party specified in Section 2. The revocation will prevent further disclosure of my health information by the party specified in Section\u003Cbr>2 from the date of receipt. I understand a delay may exist if the party specified in Section 2 is not the covered entity authorized to disclose Protected Health Information to the party specified in Section 2. I also understand that a written revocation is not effective with respect to actions the covered entity or party specified in Section 2 took in reliance on a valid Authorization, or where the Authorization was obtained as a condition of obtaining insurance coverage.\u003Cbr>3. I am signing this authorization voluntarily and understand my entitlement to treatment, payment, enrollment, or eligibility for health plan benefits will not be affected if I do not sign this HIPAA Authorization Form.\u003Cbr>4. If the party specified in Section 3 is not a HIPAA Covered Entity or Business Associate as defined in 45 CFR §160.103, the disclosed health information may no longer be protected by federal and state privacy regulations.\u003Cbr>5 (if applicable) . My substance abuse disorder records are protected under the federal regulations governing the Confidentiality of Substance Use Disorder Patient Records and cannot be redisclosed without my written authorization.\u003Cbr>6 (if applicable) . Information protected by the Reproductive Privacy Act (Cal. Health & Safety Code §123460-123469) may not be further disclosed by the party specified in Section 3 except in accordance with a new authorization that meets the requirements of the Confidentiality of Medica","cbCaiepJZQzUqrSA","https://ap.wps.com/l/cbCaiepJZQzUqrSA","pdf",152298,8,"English","# Patient/Plan Member Information\n# Authorized to Disclose PHI\n# Authorized to Receive PHI\n# Authorization Expiration\n# Health Information to be Disclosed (General)\n# Health Information to be Disclosed (Specific)\n# Purpose of the Release or Use\n# Authorization Information\n# Additional Conditions or Limitations\n# Signature (Patient/Plan Member or Authorized Signer)","[{\"question\":\"What information does Section 1 require from the patient or plan member?\",\"answer\":\"Section 1 collects the patient/plan member’s last name, first name, middle name, reference number, date of birth, and address details including city/state/ZIP.\"},{\"question\":\"How is the expiration of the PHI authorization determined?\",\"answer\":\"Section 4 states the authorization expires on the event or date specified. If the release is ongoing, enter N/A in both fields.\"},{\"question\":\"Can the patient revoke this HIPAA authorization?\",\"answer\":\"Yes. Section 8 explains the patient has the right to revoke by submitting the revocation in writing to the party listed in Section 2, and it prevents further disclosure from the receipt date.\"}]","HIPAA Authorization Form (California) - Patient/Plan Member PHI Release | PDF"]