Privacy Forms

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Authorization to Use or Disclose Protected Health Information (PHI)

Description Arabic English Farsi Korean Spanish Vietnamese
Authorization to Use or Disclose Protected Health Information (PHI)
This authorization form may be used by you as a patient/client of the County in order 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.
PDF version of Notice of Privacy Practices Employee Benefits PHI Form in Word (Arabic)
PDF version of Notice of Privacy Practices Employee Benefits PHI Form in Word (Arabic)
PHI Form in Word (Arabic)
PDF version of Notice of Privacy Practices Employee Benefits PHI Form in Word (Arabic)
Spanish PDF version of Notice of Privacy Practices Employee Benefits PHI Form in Word (Arabic)
Vietnamese PDF version of Notice of Privacy Practices Employee Benefits PHI Form in Word (Arabic)

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.