HIPAA Authorization - California

California · Fillable PDF · Free

Identify who may release your health information and who may receive it. This is separate from appointing someone to make health care decisions. You want family, a caregiver or another person to receive your medical information.

Download HIPAA Authorization - California PDF · 6 pages. No account required.

Book a notary for HIPAA Authorization - California

Who this form is for

People who want to identify recipients of health information.
Families coordinating medical records with providers.
People preparing this document alongside a health care directive.

What you'll need

Your identifying and contact information.
Names of providers and the people or organizations you want to receive information.
The information scope and expiration choices you want to review, plus photo ID for notarization.

How to complete it

Read the instructions and complete the patient, provider and recipient sections.
Review the information categories, purpose and expiration choices with a professional if needed.
Keep the supplied PDF at its original size; do not shrink or reformat it.
Follow the signature and distribution instructions. A notarized signature can help establish the signer's identity.

Related California forms

California · Fillable PDF · 11 pages · Official California form · Free

Advance Health Care Directive - California

Includes a Health Care Power of Attorney to name your health care agent, plus instructions for your medical care. This California statutory packet includes instructions and wallet cards.

View Advance Health Care Directive - California · Download Advance Health Care Directive - California

California · Fillable PDF · 6 pages · Official California form · Free

General (Financial) Power of Attorney - California

Name an agent to handle financial and property matters using California's statutory form. This form addresses finances, not health care decisions.

View General (Financial) Power of Attorney - California · Download General (Financial) Power of Attorney - California

California · Fillable PDF · 3 pages · Free

Medical Consent for a Minor - California

Authorize another adult caring for your child to consent to medical or dental care within the stated scope.

View Medical Consent for a Minor - California · Download Medical Consent for a Minor - California

California · Fillable PDF · 5 pages · Free

Revocation of Advance Health Care Directive - California

Identify an earlier health care directive or agent appointment you want to revoke. The packet includes instructions and a distribution record for notifying others.

View Revocation of Advance Health Care Directive - California · Download Revocation of Advance Health Care Directive - California

These forms are a free convenience, not legal advice. First Choice Mobile Notary & Apostille is not a law firm. Consult an attorney licensed in the relevant state for legal questions.

Free legal forms by state · Book a mobile notary