Privacy Forms

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Authorization to Use or Disclose Protected Health Information (PHI)

This authorization form may be used by you as a 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.