Click on the icon, in the table below, to download the appropriate file.
Complaint Filing Form & Fact Sheet - The HIPAA Privacy Rule allows you to make a complaint regarding violation of your privacy rights by a covered entity. If you believe that a person, agency or program covered under HIPAA violated your or someone else's health information privacy rights, or committed another violation of the Privacy Rule, you may file a complaint with the County of Orange HIPAA Privacy Officer.
Authorization to Use and Disclose Protected Health Information (PHI) This authorization form is for: County of Orange clients to request a copy of their own medical information or to request that their medical information be released to another health care provider. Third parties such as client representatives or attorney’s requesting medical information.
Revocation of Authorization to Use or Disclose Protected Health Information - This form is now required under HIPAA. If the client/patient wants to revoke an authorization, it must be done in writing and will be processed through the HCA/Custodian of Records office. Instructions available in Word or PDF format.
Request for Special Restriction on the Use or Disclosure of PHI - This form is used by a County of Orange client/patient to request restrictions on use/disclosure of their PHI.
Termination of Special Restriction This form is to be completed by client/patient or by Program to communicate and document the termination of restrictions on PHI.
Request for Restriction on the Manner/Method of Confidential Communications This form is used by a County of Orange client/patient to request alternative method of communication of their PHI.
Request to Amend PHI This form is used by a County of Orange client/patient to request an amendment to their PHI.
Statement of Disagreement/Request to Include Amendment Request and Denial with Future Disclosure
Request for an Accounting of Disclosures This form is required under HIPAA, and is used by a County of Orange client/patient to request an accounting of disclosures.
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