Program Consent California Department Of Public Health (Page 2 of 2) in pdf

Program Consent California Department Of Public Health Page 2

State of California – Health and Human Services Agency

California Department of Public Health

CONSENT AND WRITTEN AUTHORIZATION FOR USE AND

DISCLOSURE OF PERSONAL INFORMATION

OA-PCIP - INSURANCE ASSISTANCE SECTION

I, _____________________________, consent to release of personal and medical information as described

above to CDPH, my enrollment worker, MRMIB, DHHS, and MRMIB’s vendors and auditors, other health

care professionals who provide services to me, and other governmental or public agencies for the

purposes of determining eligibility (both initial eligibility and changes that may affect continuing eligibility),

in connection with the payment of premiums, to facilitate the operation of the premium payment project

and PCIP, in connection with an administrative hearings or judicial proceedings between you and MRMIB,

its third-party vendors or DHHS and in response to a subpoena or court order served on MRMIB, its

third-party vendors or DHHS. This consent shall remain in effect for two years from the date of my

signature below unless revoked by me in writing. I understand that revocation will not apply to information

that has already been released in response to this authorization. A photocopy of this consent shall be

considered as valid as the original. Any disclosure authorized by the consent form shall be made only

upon agreement that the information will be kept confidential as described above.

Applicant’s Signature

Date

Enrollment Worker’s Signature

Date

Enrollment Site Name

Enrollment Worker Name

Enrollment Site Address (Number, Street, Suite #)

City

State

Zip Code

Enrollment Site Telephone Number Enrollment Site Fax Number

Enrollment Worker E-mail Address

CDPH 8534 (11/11)

Program Consent California Department Of Public Health Page 2