Form Mc 220 - Authorization For Release Of Information (Page 3 of 4) in pdf

State of California--Health and Human Services Agency

Department of Health Care Services

Explanation of MC 220

AUTHORIZATION FOR RELEASE OF INFORMATION

We need your written authorization to help you get the information required to

process your application for disability. Laws and regulations require that sources

have an authorization before releasing information to us.

Also, laws require

authorization for the release of information about certain conditions and from

educational sources.

You can provide this authorization by signing form MC 220. Federal law permits sources

with information about you to release that information if you sign a single authorization to

release all your information from all your possible sources. If you sign such a single

authorization, we will make copies of it for each source we contact to get your information.

If for any reason we need additional authorizations, we will contact you.

The reason we need minors age 12 and older to sign an authorization, in addition to the

authorization signed by the parent/ guardian, is that a confidential physician-patient

relationship can exist between a child and his/her doctor based on Family Code,

Sections 6920–6929 under certain circumstances once the child turns 12 years of age.

HIPAA authorizes disclosure in reliance on the authorization of an unemancipated minor

when other provision of law allows the minor to authorize the treatment or care described

in the documents to be disclosed. [45 CFR § 164.502(g)(3).] Consequently, it may be

necessary to secure the child’s consent in lieu of or in addition to consent by a parent in

order to secure access to the needed information.

You have the right to revoke and/or modify this authorization at any time, except to the

extent an action has already occurred.

To do so, send a written statement to State

Programs—Disability Determination Service Division. Attention: Professional Relations

Specialist. If you do, also send a copy directly to any of your sources of information that

you no longer wish to disclose information about you. The California Department of Social

Services can tell you if we identified any sources you did not originally tell us about. As

described below, revocation or modification could result in loss of benefits.

IMPORTANT INFORMATION, INCLUDING NOTICE REQUIRED BY THE INFORMATION

PRACTICES ACT

All personal information collected by CDSS is protected by the Information Practices Act of

1977. In addition, information made or kept by CDSS or the DHCS in connection with the

Medi-Cal

program

protected

California

Welfare

and

Institutions

Code,

Section 14100.2; and Title 42, United States Code (USC), Section 1396a(a)(7).

Information is retained by CDSS in adherence to retention schedules prescribed by the

Department.

CDSS is authorized to collect the information, acting under an agreement with the DHCS,

on this form under Section 14011 of the California Welfare and Institutions Code and

regulations in Title 22, California Code of Regulations (CCR). The information on this form

is needed to make a decision on the named applicant or beneficiary’s application for, or

Page 3 of 4

MC 220 14pt (04/08)

Form Mc 220 - Authorization For Release Of Information Page 3

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