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Authorization to Use or Disclose Protected Health Information (PHI)

This authorization form may be used by you as a patient/client of the County to initiate a request to have PHI about you disclosed outside of the Health and Human Services Agency or between Programs with sensitive confidentiality requirements. 

• Arabic
• Chinese New
• English
• Farsi
• Korean
• Spanish
• Vietnamese

For additional forms, concerning your medical information please visit the Orange County Health Care Agency Custodian of Records webpage.

For more information send us an email or call (714) 568-5614.