Authorization For Release Of Protected Health Information (Page 2 of 2) in pdf

Authorization For Release Of Protected Health Information Page 2

rules of HIPAA (45 CFR §164), California law prohibits the further disclosure of this

information without a “new authorization”. It is my intention that this authorization form

be construed to be a “new authorization” that meets the requirements of California Civil

Code §56.11 for purposes of California Civil Code §56.13 to permit further authorization

by recipients of information initially received under this authorization.

The authority given to my Personal Representative herein shall supersede any

prior agreement that I may have made with any health care provider to restrict access

to, or the disclosure of, my health and medical information.

I understand that I have the right to revoke this authorization and that any such

revocation must be in writing and delivered to my Personal Representative (and to my

alternative Personal Representative) to be effective.

This authorization shall remain in full force and effect until the earlier of (1) my

written revocation hereof or (2) my death.

Any person or entity may rely upon a copy or facsimile of this document.

Dated: _____________, 2012

_________________________________

Typed name

CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC

STATE OF CALIFORNIA

)

) ss.

COUNTY OF ___________

)

On ___________, 2012, before me, __________________, a Notary Public,

personally appeared _____________ who proved to me on the basis of satisfactory

evidence to be the person(s) whose name(s) is/are subscribed to the within instrument

and acknowledged to me that he/she/they executed the same in his/her/their authorized

capacity(ies), and that by his/her/their signature(s) on the instrument, the person(s), or

the entity(ies) upon behalf of which the person(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of California

that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

__________________________________

Notary Public, State of California

Authorization For Release Of Protected Health Information Page 2