Dhcs 1807 Sp - California Autorizacion De Divulgacion De Informacion Protegida De La Salud E Informacion Confidencial - Health And Human Services Agency Page 4
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4State of California - Health and Human Services Agency
Department of Health Care Services
Unidad de Servicios del Defensor
AUTORIZACIÓN DE DIVULGACIÓN
Regla de Privacidad de la HIPAA,
DE INFORMACIÓN PROTEGIDA DE LA SALUD
Título 45 del C.F.R.),
E INFORMACIÓN CONFIDENCIAL
Sección 164.508
Código de Asistencia Social e
Instituciones, Sección 5328 (c)
_
___
Información de Identificación
Copia de Identificación Adjunta
Tipo __________________________(Licencia de Conducir de California, Tarjeta de
Identificación del Departamento de Vehículos Motorizados de California, Tarjeta de
Identificación de Empleado Estatal o Federal).
Número ________________________
Si No Se Adjunta Una Identificación, Su Firma Debe Ser Notariada.
Notariada Por ___________________________________________________
El__________________________________(Fecha)
Número de Notario Público ____________________________________________
No Es Oficial Si No Está Firmado por Un Notario Público
DHCS 1807 SP (06/2013)
Page 4 of 4
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