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CDCR Medical Form

This 3 page document contains an authorization form for the release of an inmate's medical information from California Prison Health Care Services to itself. It lists the inmate's name and identifying information. It describes the specific medical information to be released, the time period of treatment covered, and the purpose of disclosing the information. The authorization expires on a specified date unless revoked earlier in writing. The inmate signs to authorize the disclosure and acknowledge their rights regarding the release of their private health information.

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Liane Buck
Copyright
© Attribution Non-Commercial (BY-NC)
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2K views2 pages

CDCR Medical Form

This 3 page document contains an authorization form for the release of an inmate's medical information from California Prison Health Care Services to itself. It lists the inmate's name and identifying information. It describes the specific medical information to be released, the time period of treatment covered, and the purpose of disclosing the information. The authorization expires on a specified date unless revoked earlier in writing. The inmate signs to authorize the disclosure and acknowledge their rights regarding the release of their private health information.

Uploaded by

Liane Buck
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

STATE OF CALIFORNIACALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION Attachment C

AUTHORIZATION FOR RELEASE OF INFORMATION


CDCR 7385 (Rev. 05/09) Page 1 of 2

AUTHORIZATION FOR RELEASE OF INFORMATION

YOUR INFORMATION
Last Name: First Name: Middle Name: Date of Birth

Street Address: City/State/Zip: CDCR/YA #:

Person/Organization Providing the Person/Organization to Receive the


Information Information

California Prison Health Care California Prison Health Care


Services Services
Name: __________________________ Name: __________________________
Address: ________________________ Address: ________________________
City/State/Zip ____________________ City/State/Zip ____________________
Phone # : (_____) _______ _________ Phone # : (_____) _______ _________
Fax number: (______) ______ _______ Fax number: (______) ______ _______

[45 C.F.R. § 164.508(c)(1)(iii) & Civ. Code § 56.11(e), (f).]

Description of Information to be Released


(Provide a detailed description of the specific information to be released)
[45 C.F.R. § 164.508(c)(1)(i) & Civ. Code § 56.11(d) & (g).]
Medical Mental Health Genetic Testing
Dental Substance Abuse/ Alcohol Communicable Disease
HIV Psychotherapy Notes Other (Please specify
below:)
_______________________________________________________________

For the following period of time: from_____________(date) to_____________(date)

Description of Purpose for the Use or Release of the Information


Indicate how information is to be used. [45 C F R . § 164.508(c)(1)(iv).]
Health Care Personal Use Legal

Other (Please specify: _________________________________________


________________________________________________________________
STATE OF CALIFORNIACALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION Attachment C
AUTHORIZATION FOR RELEASE OF INFORMATION
CDCR 7385 (Rev. 05/09) Page 2 of 2

Will the health care provider receive money for the release of this information?
[45 C.F.R § 164.524(c)(4)(i), (ii).]
Reasonable fees may be charged to cover the cost of copying and postage.

This authorization for release of the above information to the above-named


persons/organizations will expire on: _______________(date).
[45 C.F.R. § 164.508(c)(1)(v) & Civ. Code § 56.11(h).]

I understand that:
• I authorize the use or disclosure of my individually identifiable health information
as described above for the purpose listed. I understand that this authorization is
voluntary. [45 C.F.R. § 164.508(c)(2)(i).]
• I have the right to revoke this authorization by sending a signed notice stopping
this authorization to the Health Records department at my current institution. The
authorization will stop further release of my health information on the date my
valid revocation request is received in the Health Records department. [45 C.F.R. §
164.508(c)(2)(i) & Civ. Code § 56.15.]
• I am signing this authorization voluntarily and that my treatment will not be
affected if I do not sign this authorization. [45 C.F.R. § 164.508(c)(2)(ii).]
• Under California law, the recipient of the protected health information under the
authorization is prohibited from re-disclosing the information, except with a written
authorization or as specifically required or permitted by law. (Civ. Code § 56.13)
• If the organization or person I have authorized to receive the information is not a
health plan or health care provider; the released information may no longer be
protected by federal privacy regulations. [45 C.F.R. § 164.508(c)(2)(ii).]
• I have the right to receive a copy of this authorization. [45 C.F.R. § 164.508 (c)(4) &
Civ. Code § 56.11(i)]

Signature: CDCR/YA Number: Date:

[45 C.F.R. § 164.508 (c)(vi) & Civ. Code § 56.11(c)(1)]

Representative: Relationship: Date:

[45 C.F.R. § 164.502 (g)(1) & Civ. Code § 56.11(c)(2)]

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