Alpine County, CA · Alpine County
Authorization for the Use and Disclosure of Health Information
Alpine County Behavioral Health Services uses this authorization form when a client permits health information to be exchanged with a person or organization.
At a glance
- Issued by
- City of Alpine County · Alpine County, Alpine County, California
- Notarization
- Not required: file this form without a notary.
- Official source
- alpinecountyca.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
This form authorizes Alpine County Behavioral Health Services to use or disclose a client’s health information to a named person or organization. The client identifies the information to be exchanged, the purpose, and how long the authorization remains valid. It also explains the client’s rights, including revoking the authorization in writing, and provides signature and date lines.
Who needs it
Clients who want Alpine County Behavioral Health Services to exchange specified health information with a person or organization complete this authorization.
How to submit it
Submit it to the county department named on the form; check the county website for current contact details.
About notarization
This document is signed without a notary; the signer just signs and dates it.
How to submit this form
- 1
Download the Form
Download the health information authorization form.
- 2
Complete the Form
Enter the client and authorized-person details, initial the information types, and state the purpose and authorization period.
- 3
Review the Authorization
Read the statements about disclosure and revocation, then sign, date, and print your name.
- 4
Submit to the County
Submit the completed form to the county department named on the form; check the county website for current contact details.
Frequently asked questions
- Do I need a notary for the health information authorization?
- No. The document has a signature and date line and does not require a notary; the signer just signs and dates it.
- How do I submit the health information authorization?
- Submit it to the county department named on the form. Check the county website for current contact details.
- What information does the authorization ask for?
- It asks for client and contact details, the information to be disclosed or used, the purpose, the authorization period, and the client's signature and date.
- Can I revoke this authorization?
- The form says you may revoke the authorization in writing unless disclosure has already been made or is permitted or required by law. It gives a county address for delivering revocations.