An Administrator's Guide to California Private School Law Compendium

C HAPTER 10 – P RIVACY R IGHTS O F S TUDENTS A ND E MPLOYEES D OCUMENT 10.A

HIPAA P RIVACY A UTHORIZATION F OR R ELEASE O F I NFORMATION YOUR INFORMATION Last Name: First Name:

Middle Initial:

Address:

City/State:

Zip Code:

Person/Organization Providing the Information [45 C.F.R.§ 164.508(c)(ii) & Civ. Code § 56.11(c)]

Person/Organization to Receive the Information [45 C.F.R.§ 164.508(c)(iii) & Civ. Code § 56.11(f)]

Description of the Information to be Released (Provide a detailed description of the specific information to be released) [45 C.F.R. § 164.508(c)(i)& Civ. Code § 56.11(d) & (g)]]

Description of Each Purpose for the Use or Release of the Information (Provide a detailed description of the activity for which the information will be used) [45 C.F.R. § 164.508(c)(iv)]

Will the health plan or provider receive money for the release of this information? [45 C.F.R. § 164.508(a)(3)] Yes No

An Administrator’s Guide to California Private School Law - Compendium ©2019 Liebert Cassidy Whitmore 153