AUTHORIZATION AND MEDICAL HISTORY FORMS

Transcription

1 AUTHORIZATION AND MEDICAL HISTORY FORMS TABLE OF CONTENTS 1. All-Purpose Authorization - Medical, Employment, Scholastic and Insurance Records. HIPAA Compliant 2. Medical Authorization - Medical, Alcohol, Drug, Psychiatric and HIV/AIDS Records. HIPAA Compliant 3. Medical History Form - Have Claimant Complete this Form 4. Employment History Form - Have Claimant Complete this Form 5. Social Security - Earnings & Benefits Information - Basic (SSA-7004-SM) (2 pages) 6. Social Security - Earnings & Benefits Information - Detail (SSA-7050-F4) (4 pages) 7. Social Security - General Information and Medical 8. Military Records - SF 180, Request Pertaining to Military Records, All Services and National Guard, National Personnel Records Center (8-1/2 x 14" legal sized form) 9. Military Dependant - Medical Records 10. Military Records - Request for Information Needed to Locate Medical Records 11. Veteran's Administration Medical Records- FORM FORM (page 1) 12. Veteran's Administration - FORM (page 2) 13. Kaiser Authorization Form - HIPAA Compliant 14. UC Davis Authorization - Form Rev. (1/09) 15. Blue Cross Authorization Form HIPAA Compliant 16. Blue Shield Authorization Form - Form C15625 Rev. (1/10) 17. Cigna Authorization - Form c Rev. (05/08) 18. Guardian Authorization - Form GG WRO 19. Health Net Authorization HIPAA Compliant 20. Medicare Beneficiary Authorization HIPAA Compliant 21. Department of Health Care Services (Medi-Cal) Form DHCS 6236 Rev. (11/07) 22. Medi-Cal Authorization Form 6237 Parent, guardian or court appointed authority on behalf 23. Employment Development Department 24. UCLA Health System Authorization Form #30910 Rev. (04/08) 25. Naval Medical Center (Medical or Dental) Form DD 2870 Rev. (12/03) Authorization Forms in Spanish 27. Regular Authorization - Spanish Version. HIPAA Compliant 28. Medical Authorization - Spanish Version. HIPAA Compliant Please call Macro-Pro Client Service if you require any assistance with these forms, have any questions, need additional copies or if you would like us to provide you with a different form. (888) You can also download the forms at

2 HIPAA-COMPLIANT AUTHORIZATION FOR THE RELEASE OF RECORDS 1.) I hereby authorize: Name of Facility with Records/Disclosing Party 2.) To disclose to: Name of Requesting Party (Requester): Insurance Carrier/Third Party Administrator/Self-Insured Employer/Attorney Firm and/or their attorneys, through Macro-Pro their agent, to review, inspect, and/or photocopy any and all of the following from any and all dates which are in your possession or control: Medical records, to include but not limited to: Medical files, reports, charts, graphs, notes, tests, x-rays, MRI s, billings and laboratory reports. Employment and/or Union records to include but not limited to: Personnel file, medical and insurance, pension benefit records and wage records. EDD Disability and Unemployment Records Scholastic Records Insurance and Claim Records Police, Prison or Probation Records SENSITIVE INFORMATION: By marking the boxes below, I hereby authorize the release of information concerning: HIV and/or AIDS Information Psychiatric and Mental Health Information Sexually Transmitted Disease Information Alcohol and/or Drug Information Genetic Records The health information authorized on this form will be used for the following purposes only: Discovery for a Liability or Workers Compensation claim. DURATION: This authorization shall become effective immediately and shall remain in effect until or for ONE full year from date of signature. REVOCATION: This authorization is subject to written revocation by the undersigned at any time between now and the disclosure of information by the disclosing party. My written revocation will be effective upon receipt but will not be effective to the extent that the requester or others have acted in reliance upon this authorization. Written revocation is to be sent to those parties listed on line 1.) and line 2.) above. REDISCLOSURE: I understand that the requester may not lawfully further use or disclose the health information unless another authorization is obtained from me or unless such use and disclosure is specifically required or permitted by law. I understand that I have the right to receive a copy of this authorization. A copy of this authorization shall be considered as valid as the original. Signature Print Name Date If Signed by Other than Patient, Indicate Relationship AUTHORIZATION HIPAA

3 AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION 1.) I hereby authorize: Name of Facility with Records/Disclosing Party 2.) To disclose to: Name of Requesting Party (Requester): Insurance Carrier/Third Party Administrator/Self-Insured Employer/Attorney Firm and/or their attorneys, through Macro-Pro, Inc., their agent, to review, inspect, and/or photocopy records and information pertaining to: / / Name of Patient (List Other Names Used) Date of Birth ( ) - Address Daytime Telephone Number INITIAL OR SIGN 1 through 6 To Specify Records To Be Disclosed: 1. Medical Information 4. Medical Billing Initial Initial 2. Psychiatric Information 5. X-Rays And Films Signature Date 3. Drug/Alcohol Information 6. HIV/Aids Testing, Diagnosis & Treatment Signature Date Signature Date OTHER HEALTH INFORMATION TO BE DISCLOSED: The requester may use the health information authorized on this form for the following purposes only: DURATION: This authorization shall become effective immediately and shall remain in effect until or for ONE full year from date of signature. Date REVOCATION: This authorization is also subject to written revocation by the undersigned at any time between now and the disclosure of information by the disclosing party. My written revocation will be effective upon receipt but will not be effective to the extent that the requester or others have acted in reliance upon this authorization. Written revocation is to be sent to those parties listed on line 1.) and line 2.) above. REDISCLOSURE: I understand that the requester may not lawfully further use or disclose the health information unless another authorization is obtained from me or unless such use or disclosure is specifically required or permitted by law. I understand that I have the right to receive a copy of this authorization. A copy of this authorization shall be considered as valid as the original. Signature Print Name Date AUTHORIZATION 2003-HIPAA 14 point Initial

4 MEDICAL HISTORY Employee Address City, State, Zip Code Employer Date Of Injury Daytime Telephone Number Please list below all hospitals and doctors including medical doctors (MD), chiropractors (DC), osteopaths (DO), physical therapists, psychologists, psychiatrists, or any other medical care provider you have seen in the last 10 (ten) years. Name, Address & Phone # Of Providers Treatment Date(s) Type Of Treatment Signature Date MACRO-PRO AUTH95-1

5 EMPLOYMENT HISTORY EMPLOYEE ADDRESS EMPLOYER DATE OF INJURY Please list below all past employers for the last 10 years. NAME, ADDRESS & PHONE NUMBERS OF EMPLOYER EMPLOYMENT DATES SIGNATURE DATE MACRO

6 Request for Social Security Statement Form Approved OMB No SP Please check this box if you want to get your Statement in Spanish instead of English. Please print or type your answers. When you have completed the form, fold it and mail it to us. If you prefer to send your request using the Internet, go to 1. Name shown on your Social Security card: First Name Last Name Only 2. Your Social Security number as shown on your card: 3. Your date of birth (Mo.-Day-Yr.) 4. Other Social Security numbers you have used: 5. Your Sex: Male Female Form SSA-7004-SM ( ) EF ( ) edition may be used Middle Initial For items 6 and 8, show only earnings covered by Social Security. Do NOT include wages from state, local or federal government employment that are NOT covered by Social Security or that are covered ONLY by Medicare. 6. Show your actual earnings (wages and/or net self-employment income) for last year and your estimated earnings for this year. A. Last year s actual earnings: (Dollars Only) $,. 0 0 B. This year s estimated earnings: (Dollars Only) $, Show the age at which you plan to stop working: (Show only one age) 8. Below, show the average yearly amount (not your total future lifetime earnings) that you think you will earn between now and when you plan to stop working. Include performance or scheduled pay increases or bonuses, but not cost-of-living increases. If you expect to earn significantly more or less in the future due to promotions, job changes, parttime work or an absence from the work force, enter the amount that most closely reflects your future average yearly earnings. If you don t expect any significant changes, show the same amount you are earning now (the amount in 6B). Future average yearly earnings: (Dollars Only) $,. 0 0 Printed on recycled paper 9. Do you want us to send the Statement: To you? Enter your name and mailing address. To someone else (your accountant, pension plan, etc.)? Enter your name with c/o and the name and address of that person or organization. C/O or Street Address (Include Apt. No., P.O. Box, Rural Route) Street Address Street Address (If Foreign Address, enter City, Province, Postal Code) U.S. City, State, ZIP code (If Foreign Address, enter Name of Country only) NOTICE: I am asking for information about my own Social Security record or the record of a person I am authorized to represent. I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. I authorize you to use a contractor to send the Social Security Statement to the person and address in item 9. Please sign your name (Do Not Print) Date (Area Code) Daytime Telephone No.

7 SOCIAL SECURITY ADMINISTRATION About The Privacy Act Social Security is allowed to collect the facts on this form under section 205 of the Social Security Act. We need them to quickly identify your record and prepare the Statement you asked us for. Giving us these facts is voluntary. However, without them we may not be able to give you a Statement. Neither the Social Security Administration nor its contractor will use the information for any other purpose. Paperwork Reduction Act Notice This information collection meets the requirements of 44 U. S. C. 3507, as amended by Section 2 of the Paperwork Reduction Act of You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 5 minutes to read the instructions, gather the facts and answer the questions. You may send comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD Send only comments relating to our time estimate to this address, not the completed form. Request for Social Security Statement Within four to six weeks after you return this form, we will send you: a record of your earnings history; an estimate of how much you have paid in Social Security taxes; and estimates of benefits you (and your family) may be eligible for now and in the future. Please note: If you have been receiving a Social Security Statement each year about three months before your birthday, this request will stop your next scheduled mailing. You will not receive a scheduled Statement until the following year. We hope you will find the Statement useful in planning your financial future. Remember, Social Security is more than a program for retired people. It helps people of all ages in many ways. For example, it can help support your family in the event of your death and pay you benefits if you become severely disabled. If you have questions about Social Security or this form, please call our toll-free number,

8 REQUEST FOR SOCIAL SECURITY EARNINGS INFORMATION *Use This Form If You Need 1. Certified/Non-Certified Detailed Earnings Information Includes periods of employment or self-employment and the names and addresses of employers. OR 2. Certified Yearly Totals of Earnings Includes total earnings for each year but does not include the names and addresses of employers. Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. 3507, as amended by section 2 of the Paperwork Reduction Act of You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 11 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies in your telephone directory or you may call Social Security at (TTY ). You may send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD Send only comments relating to our time estimate to this address, not the completed form. Yes, we usually charge a fee for detailed information. In most cases, this information is used for purposes NOT directly related to Social Security such as for a private pension plan or personal injury suit. The fee chart on page 3 gives the amount of the charge. Sometimes, there is no charge for detailed information. If you have reason to believe your earnings are not correct (for example, you have previously received earnings information from us DO NOT USE THIS FORM FOR: Non-certified yearly totals of earnings This service is free to the public. Form Approved OMB No These totals can be obtained by calling to receive Form SSA-7004, Request for Earnings and Benefit Estimate Statement. PRIVACY ACT NOTICE: We are authorized to collect this information under section 205 of the Social Security Act, and the Federal Records Act of 1950 (64 Stat. 583). It is needed so we can identify your records and prepare the statement you request. You do not have to furnish the information, but failure to do so may prevent your request from being processed. How Do I Get This Information? You need to complete the attached form to tell us what information you want. Can I Get This Information For Someone Else? Yes, if you have their written permission. For more information, see page 3. Who Can Sign On Behalf Of The Individual? The parent of a minor child, or the legal guardian of an individual who has been declared legally incompetent, may sign if he/she is acting on behalf of the individual. Is There A Fee For This Information? 1. Certified/Non-Certified Detailed Earnings Information INFORMATION ABOUT YOUR REQUEST and it does not agree with your records), we will supply you with more detail for the period in question. Occasionally, earnings amounts are wrong because an employer did not correctly report earnings or earnings are credited to the wrong person. In situations like these, we will send you detailed information, at no charge, so we can correct your record. Be sure to show the year(s) involved on the request form and explain why you need the information. If you do not tell us why you need the information, we will charge a fee. We will certify the detailed earnings information for an additional fee of $ Certification is usually not necessary unless you plan to use the information in court. 2. Certified Yearly Total of Earnings Yes, there is a fee of $15 to certify yearly totals of earnings. Cetification is usually not necessary unless you plan to use the information in court. 3. Method of Payment Enclose a check or money order for the entire fee required. Payment can also be made by credit card. To do so, complete page 4 of this form and return it with your request form. Form SSA-7050-F4 ( ) EF ( ) Destroy prior editions

9 Name REQUEST FOR SOCIAL SECURITY EARNINGS INFORMATION 1. From whose record do you need the earnings information? Print the Name, Social Security Number (SSN), and date of birth below. Social Security Number Other Name(s) Used (Include Maiden Name) Date of Birth (Mo/Day/Yr) 2. What kind of information do you need? Detailed Earnings Information (If you check this block, tell us below why you need this information.) For the period(s)/year(s): Certified Total Earnings For Each Year. (Check this box only if you want the information certified. Otherwise, call to request Form SSA-7004, Request for Earnings and Benefit Estimate Statement) For the year(s): 3. If you owe us a fee for this detailed earnings information, enter the amount due using the chart on page A. $ Do you want us to certify the information? Yes No If yes, enter $15.00 B. $ ADD the amounts on lines A and B, and enter the TOTAL amount I am the individual to whom the record pertains (or a person who is authorized to sign on behalf of that individual). I understand that any false representation to knowingly and willfully obtain information from Social Security records is punishable by a fine of not more than $5,000 or one year in prison. C. $ You can pay by CREDIT CARD by completing and returning the form on page 4, or Send your CHECK or MONEY ORDER for the amount on line C with the request and make check or money order payble to "Social Security Administration" DO NOT SEND CASH. SIGN your name here (Do not print) > Date Daytime Phone Number (Area Code) (Telephone Number) 5. Tell us where you want the information sent. (Please print) Name Address City, State & Zip Code 6. Mail Completed Form(s) To: Exception: If using private contractor (e.g., FedEx) to mail form(s), use: Social Security Administration Division of Earnings Record Operations P.O. Box Baltimore Maryland Form SSA-7050-F4 ( ) EF ( ) 2 Social Security Administration Division of Earnings Record Operations 300 N. Greene St. Baltimore Maryland

10 REQUEST FOR SOCIAL SECURITY EARNINGS INFORMATION How Much Do I Have to Pay For Detailed Earnings? 1. Count the number of years for which you need detailed earnings information. Be sure to add in both the first and last year requested. However, do not add in the current calendar year since this information is not yet available. 2. Use the chart below to determine the correct fee. Number of Years Requested Fee Number of Years Requested Fee Number of Years Requested Fee 1 $ $ $ For Requests Over 40 Years, Please Add 1 Dollar for Each Additional Year. Whose Earnings Can Be Requested 1. Your Earnings You can request earnings information from your own record by completing the attached form; we need your handwritten signature. If you sign with an "X", your mark must be witnessed by two disinterested persons who must sign their name and address. 2. Someone Else's Earnings You can request earnings information from the record of someone else if that person tells us in writing to give the information to you. This writing or "authorization" must be presented to us within 60 days of the date it was signed by that person. 3. A Deceased Person's Earnings You can request earnings information from the record of a deceased person if you are the legal representative of the estate, a survivor (that is, the spouse, parent, child, divorced spouse of divorced parent), or an individual with a material interest (example-financial) who is an heir at law, next of kin, beneficiary under the will or donee of property of the decedent. Proof of death must be included with your request. Proof of appointment as representative or proof of your relationship to the deceased must also be included. Form SSA-7050-F4 ( ) EF ( ) 3

11 YOU CAN MAKE YOUR PAYMENT BY CREDIT CARD As a convenience, we offer you the option to make your payment by credit card. However, regular credit card rules will apply. You may also pay by check or money order. Please fill in all the information below and return this form along with your request to: Social Security Administration Division of Earnings Record Operations P.O. Box Baltimore Maryland Note: Please read Paperwork/Privacy Act Notice Exception: If using private contractor (e.g., FedEx) to mail form(s), use: Social Security Administration Division of Earnings Record Operations 300 N. Greene St. Baltimore Maryland CHECK ONE Visa MasterCard American Express Discover Diners Card Credit Card Holder's Name (Enter the name from the credit card) First Name, Middle Initial, Last Name Credit Card Holder's Address Number & Street City, State, & Zip Code Daytime Telephone Number Area Code Telephone Number Credit Card Number Credit Card Expiration Date Month Year Amount Charged $ Credit Card Holder's Signature Authorization DO NOT WRITE IN THIS SPACE OFFICE USE ONLY Name Remittance Control # Date Form SSA-7050-F4 ( ) EF ( ) 4 PRIVACY ACT NOTICE The Social Security Administration (SSA) has authority to collect the information requested on this form under section 205 of the Social Security Act. Giving us this information is voluntary. You do not have to do it. We will need this information only if you choose to make payment by credit card. You do not need to fill out this form if you choose another means of payment (for example, by check or money order). If you choose the credit card payment option, we will provide the information you give us to the banks handling your credit card account and SSA's account. We may also provide this information to another person or government agency to comply with federal laws requiring the release of information from our records. You can find these and other routine uses of information provided to SSA listed in the Federal Register. If you want more information about this, you may call or write any Social Security Office.

12 Social Security Administration Consent for Release of Information Please read these instructions carefully before completing this form. Form Approved OMB No When to Use This Form Complete this form only if you want the Social Security Administration to give information or records about you to an individual or group (for example, a doctor or an insurance company). Natural or adoptive parents or a legal guardian, acting on behalf of a minor, who want us to release the minor's: nonmedical records, should use this form. medical records, should not use this form, but should contact us. Note: Do not use this form to request information about your earnings or employment history. To do this, complete Form SSA-7050-F4. You can get this form at any Social Security office. How to Complete This Form This consent form must be completed and signed only by: the person to whom the information or record applies, or the parent or legal guardian of a minor to whom the nonmedical information applies, or the legal guardian of a legally incompetent adult to whom the information applies. To complete this form: Fill in the name, date of birth, and Social Security Number of the person to whom the information applies. Fill in the name and address of the individual or group to which we will send the information. Fill in the reason you are requesting the information. Check the type(s) of information you want us to release. Sign and date the form. If you are not the person whose record we will release, please state your relationship to that person. PRIVACY ACT NOTICE: The Privacy Act Notice requires us to notify you that we are authorized to collect this information by section 3 of the Privacy Act. You do not have to provide the information requested. However, we cannot release information or records about you to another person or organization without your consent for release of information. Your records are confidential. We will release only records that you authorize, and only to persons or organizations who you authorize to receive that information. PAPERWORK REDUCTION ACT STATEMENT: This information collection meets the clearance requirements of 44 U.S.C. 3507, as amended by section 2 of the Paperwork Reduction Act of You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 3 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U.S. Government agencies in your telephone directory or you may call Social Security at You may send comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD Send only comments relating to our time estimate to this address, not the completed form. Form SSA-3288 (5-2007) EF (5-2007)

13 Social Security Administration Consent for Release of Information TO: Social Security Administration Form Approved OMB No Name Date of Birth Social Security Number I authorize the Social Security Administration to release information or records about me to: NAME ADDRESS I want this information released because: (There may be a charge for releasing information.) Please release the following information: I am the individual to whom the information/record applies or that person's parent (if a minor) or legal guardian. I know that if I make any representation which I know is false to obtain information from Social Security records, I could be punished by a fine or imprisonment or both. Signature: Date: Social Security Number Identifying information (includes date and place of birth, parents' names) Monthly Social Security benefit amount Monthly Supplemental Security Income payment amount Information about benefits/payments I received from to Information about my Medicare claim/coverage from to (specify) Medical records Record(s) from my file (specify) Other (specify) (Show signatures, names, and addresses of two people if signed by mark.) Form SSA-3288 (5-2007) EF (5-2007) Relationship:

14 INSTRUCTION AND INFORMATION SHEET FOR SF 180, REQUEST PERTAINING TO MILITARY RECORDS 1. General Information. The Standard Form 180, Request Pertaining to Military Records (SF180) is used to request information from military records. Certain identifying information is necessary to determine the location of an individual's record of military service. Please try to answer each item on the SF 180. If you do not have and cannot obtain the information for an item, show "NA," meaning the information is "not available." Include as much of the requested information as you can. To determine where to mail this request see Page 2 of the SF180 for record locations and facility addresses. Online requests may be submitted to the National Personnel Records Center (NPRC) by a veteran or deceased veteran s next of kin using evetrecs at 2. Personnel records and Service Treatment Records (STR). Personnel records of military members who were discharged, retired, or died in service less than 62 years ago and STR s are in the legal custody of the military service department and are administered in accordance with rules issued by the Department of Defense and the Department of Homeland Security (DHS, Coast Guard). STR s of persons on active duty are generally kept at the local servicing clinic, and usually are available from the Department of Veterans Affairs approximately 40 days after the last day of active duty. (See item 3, Archival Records, if the military member was discharged, retired or died in service over 62 years ago.) a. Release of information: Release of information is subject to restrictions imposed by the military services consistent with Department of Defense regulations and the provisions of the Freedom of Information Act (FOIA) and the Privacy Act of The service member (either past or present) or the member's legal guardian has access to almost any information contained in that member's own record. An authorization signature, of the service member or the member's legal guardian, is needed in Section III of the SF180. Others requesting information from military personnel records and/or STR s must have the release authorization in Section III of the SF 180 signed by the member or legal guardian. If the appropriate signature cannot be obtained, only limited types of information can be provided. If the former member is deceased, surviving next of kin may, under certain circumstances, be entitled to greater access to a deceased veteran's records than a member of the general public. The next of kin may be any of the following: unremarried surviving spouse, father, mother, son, daughter, sister, or brother. Requesters must provide proof of death, such as a copy of a death certificate, letter from funeral home or obituary. b. Fees for records: There is no charge for most services provided to service members or next of kin of deceased veterans. A nominal fee is charged for certain types of service. In most instances service fees cannot be determined in advance. If your request involves a service fee, you will be notified as soon as that determination is made. 3. Archival Records. Personnel records of military members who were discharged, retired, or died in service 62 or more years ago have been transferred to the legal custody of NARA and are referred to as archival records. a. Release of Information: Archival records are open to the public. The Privacy Act of 1974 does not apply to archival records, therefore, written authorization from the veteran or next of kin is not required. However, in order to protect the privacy of the veteran, his/her family, and third parties named in the records, the personal privacy exemption of the Freedom of Information Act (5 U.S.C. 552 (b) (6)) may still apply and preclude the release of some information. b. Fees for Archival Records: Access to archival records is granted by offering copies of the records for a fee (44 U.S.C (c)). You will be notified if there is a charge for photocopies of documents contained in the record you are requesting. 4. Where reply may be sent. The reply may be sent to the service member or any other address designated by the service member or other authorized requester. 5. Definitions and abbreviations. DISCHARGED -- the individual has no current military status; SERVICE TREATMENT RECORD (STR) -- The chronology of medical, mental health and dental care received by service members during the course of their military career (does not include records of treatment while hospitalized); TDRL Temporary Disability Retired List. 6. Service completed before World War I. National Archives Trust Fund (NATF) forms must be used to request these records. Obtain the forms by from [email protected] or write to the Code 6 address on page 2 of the SF 180. PRIVACY ACT OF 1974 COMPLIANCE INFORMATION The following information is provided in accordance with 5 U.S.C. 552a(e)(3) and applies to this form. Authority for collection of the information is 44 U.S.C. 2907, 3101, and 3103, and Public Law (April 26, 1996), as amended in title 31, section Disclosure of the information is voluntary. If the requested information is not provided, it may delay servicing your inquiry because the facility servicing the service member's record may not have all of the information needed to locate it. The purpose of the information on this form is to assist the facility servicing the records (see the address list) in locating the correct military service record(s) or information to answer your inquiry. This form is then retained as a record of disclosure. The form may also be disclosed to Department of Defense components, the Department of Veterans Affairs, the Department of Homeland Security (DHS, U.S. Coast Guard), or the National Archives and Records Administration when the original custodian of the military health and personnel records transfers all or part of those records to that agency. If the service member was a member of the National Guard, the form may also be disclosed to the Adjutant General of the appropriate state, District of Columbia, or Puerto Rico, where he or she served. PAPERWORK REDUCTION ACT PUBLIC BURDEN STATEMENT Public burden reporting for this collection of information is estimated to be five minutes per request, including time for reviewing instructions and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to National Archives and Records Administration (NHP), 8601 Adelphi Road, College Park, MD DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. SEND COMPLETED FORMS AS INDICATED IN THE ADDRESS LIST ON PAGE 2 OF THE SF 180.

15 Standard Form 180 (Rev. 09/08) (Page 1) Authorized for local reproduction Prescribed by NARA (36 CFR (b)) Previous edition unusable OMB No Expires 10/31/2011 REQUEST PERTAINING TO MILITARY RECORDS * Requests from veterans or deceased veteran s next-of-kin may be submitted online by using evetrecs at * (To ensure the best possible service, please thoroughly review the accompanying instructions before filling out this form. Please print clearly or type.) SECTION I - INFORMATION NEEDED TO LOCATE RECORDS (Furnish as much as possible.) 1. NAME USED DURING SERVICE (last, first, and middle) 2. SOCIAL SECURITY NO. 3. DATE OF BIRTH 4. PLACE OF BIRTH 5. SERVICE, PAST AND PRESENT (For an effective records search, it is important that all service be shown below.) SERVICE NUMBER BRANCH OF SERVICE DATE ENTERED DATE RELEASED OFFICER ENLISTED (If unknown, write unknown ) a. ACTIVE COMPONENT b. RESERVE COMPONENT c. NATIONAL GUARD 6. IS THIS PERSON DECEASED? If YES enter the date of death. 7. IS (WAS) THIS PERSON RETIRED FROM MILITARY SERVICE? NO YES NO YES SECTION II INFORMATION AND/OR DOCUMENTS REQUESTED 1. CHECK THE ITEM(S) YOU WOULD LIKE TO REQUEST A COPY OF: DD Form 214 or equivalent. This form contains information normally needed to verify military service. A copy may be sent to the veteran, the deceased veteran s next of kin, or other persons or organizations if authorized in Section III, below. NOTE: If more than one period of service was performed, even in the same branch, there may be more than one DD214. Check the appropriate box below to specify a deleted or undeleted copy. When was the DD Form(s) 214 issued? YEAR(S): UNDELETED: Ordinarily required to determine eligibility for benefits. Sensitive items, such as, the character of separation, authority for separation, reason for separation, reenlistment eligibility code, separation (SPD/SPN) code, and dates of time lost are usually shown. DELETED: The following items are deleted: authority for separation, reason for separation, reenlistment eligibility code, separation (SPD/SPN) code, and for separations after June 30, 1979, character of separation and dates of time lost. All Documents in Official Military Personnel File (OMPF) Medical Records (Includes Service Treatment Records (outpatient), inpatient and dental records.) If hospitalized, provide facility name and date for each admission: Other (Specify): 2. PURPOSE: (An explanation of the purpose of the request is strictly voluntary; however, such information may help to provide the best possible response and may result in a faster reply. Information provided will in no way be used to make a decision to deny the request.) Check appropriate box: Benefits Employment VA Loan Programs Medical Medals/Awards Genealogy Correction Personal Other, explain: SECTION III - RETURN ADDRESS AND SIGNATURE 1. REQUESTER IS: (Signature Required in # 3 below of veteran, next of kin, legal guardian, authorized government agent or other authorized representative. If other authorized representative, provide copy of authorization letter.) Military service member or veteran identified in Section I, above Next of kin of deceased veteran (Must provide proof of death). Show relationship: (See item 2a on accompanying instructions.) 2. SEND INFORMATION/DOCUMENTS TO: (Please print or type. See item 4 on accompanying instructions.) Legal guardian (Must submit copy of court appointment.) Other (specify) 3. AUTHORIZATION SIGNATURE REQUIRED (See items 2a or 3a on accompanying instructions.) I declare (or certify, verify, or state) under penalty of perjury under the laws of the United States of America that the information in this Section III is true and correct. Name Signature Required - Do not print ( ) Street Apt. Date of this request Daytime phone City State Zip Code address *This form is available at on the National Archives and Records Administration (NARA) web site.*

16 Standard Form 180 (Rev. 09/08) (Page 2) Authorized for local reproduction Prescribed by NARA (36 CFR (b)) Previous edition unusable OMB No Expires 10/31/2011 LOCATION OF MILITARY RECORDS The various categories of military service records are described in the chart below. For each category there is a code number which indicates the address at the bottom of the page to which this request should be sent. Please refer to the Instruction and Information Sheet accompanying this form as needed. BRANCH CURRENT STATUS OF SERVICE MEMBER Personnel Record AIR FORCE COAST GUARD MARINE CORPS ARMY NAVY ADDRESS CODE Service Treatment Record Discharged, deceased, or retired before 5/1/ Discharged, deceased, or retired 5/1/1994 9/30/ Discharged, deceased, or retired on or after 10/1/ Active (including National Guard on active duty in the Air Force), TDRL, or general officers retired with pay 1 Reserve, retired reserve in nonpay status, current National Guard officers not on active duty in the Air Force, or National Guard released from active duty in the Air Force 2 Current National Guard enlisted not on active duty in the Air Force 13 Discharge, deceased, or retired before 1/1/ Discharged, deceased, or retired 1/1/1898 3/31/ Discharged, deceased, or retired on or after 4/1/ Active, reserve, or TDRL 3 Discharged, deceased, or retired before 1/1/ Discharged, deceased, or retired 1/1/1905 4/30/ Discharged, deceased, or retired 5/1/ /31/ Discharged, deceased, or retired on or after 1/1/ Individual Ready Reserve 5 Active, Selected Marine Corps Reserve, TDRL 4 Discharged, deceased, or retired before 11/1/1912 (enlisted) or before 7/1/1917 (officer) 6 Discharged, deceased, or retired 11/1/ /15/1992 (enlisted) or 7/1/ /15/1992 (officer) Discharged, deceased, or retired after 10/16/ Reserve; or active duty records of current National Guard members who performed service in the U.S. Army before 7/1/ Active enlisted (including National Guard on active duty in the U.S. Army) or TDRL enlisted 9 Active officers (including National Guard on active duty in the U.S. Army) or TDRL officers 8 Current National Guard enlisted and officer not on active duty in Army (including records of Army active duty performed after 6/30/1972) 13 Discharged, deceased, or retired before 1/1/1886 (enlisted) or before 1/1/1903 (officer) 6 Discharged, deceased, or retired 1/1/1886 1/30/1994 (enlisted) or 1/1/1903 1/30/1994 (officer) Discharged, deceased, or retired 1/31/ /31/ Discharged, deceased, or retired on or after 1/1/ Active, reserve, or TDRL 10 PHS Public Health Service - Commissioned Corps officers only 12 ADDRESS LIST OF CUSTODIANS (BY CODE NUMBERS SHOWN ABOVE) Where to write/send this form 1 Air Force Personnel Center HQ AFPC/DPSSRP 550 C Street West, Suite 19 Randolph AFB, TX National Archives & Records Administration Old Military and Civil Records (NWCTB-Military) Textual Services Division 700 Pennsylvania Ave., N.W. Washington, DC Department of Veterans Affairs Records Management Center P.O. Box 5020 St. Louis, MO Air Reserve Personnel Center /DSMR HQ ARPC/DPSSA/B 6760 E. Irvington Place, Suite 4600 Denver, CO U.S. Army Human Resources Command ATTN: AHRC-PAV-V 1 Reserve Way St. Louis, MO Division of Commissioned Corps Officer Support ATTN: Records Officer 1101 Wooton Parkway, Plaza Level, Suite 100 Rockville, MD Commander, CGPC-adm-3 USCG Personnel Command 4200 Wilson Blvd., Suite 1100 Arlington, VA U.S. Army Human Resources Command ATTN: AHRC-MSR 200 Stovall Street Alexandria, VA The Adjutant General (of the appropriate state, DC, or Puerto Rico) 4 5 Headquarters U.S. Marine Corps Personnel Management Support Branch (MMSB-10) 2008 Elliot Road Quantico, VA Marine Corps Mobilization Command Andrews Road Kansas City, MO Commander USAEREC ATTN: PCRE-F 8899 E. 56th St. Indianapolis, IN Navy Personnel Command (PERS-312E) 5720 Integrity Drive Millington, TN National Personnel Records Center (Military Personnel Records) 9700 Page Ave. St. Louis, MO

17 AUTHORIZATION FOR MILITARY DEPENDENT S RECORDS TO THE NATIONAL PERSONNEL RECORDS CENTER: I hereby request and authorize you to furnish to MACRO-PRO, INCORPORATED or its representative, any and all medical information in your possession concerning: I also authorize release of a copy of the records to: Date: Signed: Patient s Date of Birth: Patient s Social Security Number: Sponsor s Name: Sponsor s Date of Birth: Sponsor s Social Security Number: Sponsor s Branch of Service: Sponsor s Current Military Status: Sponsor s Relationship to Patient: Mil Auth/95-pp

18 REQUEST FOR INFORMATION NEEDED TO LOCATE MEDICAL RECORDS We need additional information in order to service your request. Please return this form and your original request. PRIVACY ACT OF 1974 COMPLIANCE INFORMATION AUTHORITY FOR COLLECTION OF THE INFORMATION IS 44 U. S. C AND 3103, AND E.O. 9397, OF NOVEMBER 22, DISCLOSURE OF THE INFORMATION IS VOLUNTARY. THE PRINCIPAL PURPOSE OF THE INFORMATION IS TO ASSIST THE NATIONAL PERSONNEL RECORDS CENTER IN LOCATING AND VERIFYING THE CORRECTNESS OF THE REQUESTED RECORDS OR INFORMATION TO ANSWER YOUR INQUIRY. ROUTINE USES OF THE INFORMATION AS ESTABLISHED AND PUBLISHED IN ACCORDANCE WITH 5 U. S. C. 552A (E) (4) (D) INCLUDE THE TRANSFER OF RELEVANT INFORMATION TO THE APPROPRIATE FEDERAL, STATE, LOCAL OR FOREIGN AGENCIES FOR USE IN CIVIL, CRIMINAL OR REGULATORY INVESTIGATIONS OR PROSECUTION. IN ADDITION, THIS FORM WILL BE FILED WITH THE APPROPRIATE MILITARY OR CIVILIAN RECORDS AND MAY BE TRANSFERRED, ALONG WITH THE RECORD, TO ANOTHER AGENCY IN ACCORDANCE WITH THE ROUTINE USES ESTABLISHED BY THE AGENCY WHICH MAINTAINS THE RECORD. IF THE REQUESTED INFORMATION IS NOT PROVIDED, IT MAY NOT BE POSSIBLE TO SERVICE YOUR INQUIRY. NAME OF PATIENT (Please Print) SO CIAL SECURITY NO. DATE STATUS OF PATIENT AT TIME OF TREATMENT: (Check One and furnish information requested in space provided.) MILITARY FEDERAL EMPLOYEE Branch of Service Date of Birth Service Number Social Security Number DEPENDANT OF MILITARY Federal Employee Separation Date Sponsor s Name Sponsor s Service Number DEPENDANT OR FEDERAL EMPLOYEE Sponsor s Social Security Number Federal Employee s Name Branch of Service Federal Employee s Date of Birth Federal Employee s Social Security Number OTHER (Specify) SIGNATURE (Patient, parent or legal guardian) IMPORTANT: List all dates and places of treatment, especially the last date and place of treatment. NATURE OF ILLNESS, INJURY TREATMENT DATES Out- In- NAME, NUMERICAL DESIGNATION, AND LOCATION OF OR TREATMENT From (Mo/Yr) to (Mo/Yr) Patient Patient HOSPITAL, DISPENSARY, OR MEDICAL FACILITY. TO PROVIDE THE INFORMATION REQUESTED, WE MUST HAVE A SIGNED RELEASE FROM THE PERSON WHOSE RECO RDS ARE INVOLVED. IN THE CASE OF A MINOR DEPENDANT, THE PARENT OR LEGAL GUARDIAN MUST SIGN THE RELEASE. IF THE PERSON IS DECEASED OR MENTALLY INC OMPETENT, THE NEXT O F KIN OR LEGAL REPRESENTATIVE MUST SIGN. (The legal representative, guardian, or next of kin should furnish a copy of the court appointment or court order proving incapacity. For purposes of release authorization, the next of kin is defined as any of the following: unremarried widow or widower, son or daughter, father or mother, brother or sister.) RETURN TO: NATIONAL ARCHIVES AND RECORDS ADMINISTRATION NATIONAL PERSONNEL RECORDS CENTER Military Personnel Records 9700 Page Avenue St. Louis, MO Civilian Personnel Records 111 Winnebago Street St. Louis, MO NCP

19 REQUEST FOR AND CONSENT TO THE RELEASE OF INFORMATION FROM CLAIMANTS RECORDS NOTE: The execution of this form does not authorize the release of information other than that specifically described below. The information requested on this form is solicited under Title 38, United States Code, and will authorize release of the information you specify. The information may also be disclosed outside the VA as permitted by law to include disclosures as stated in the Notices of Systems of VA Records published in the Federal Register in accordance with the Privacy Act of Disclosure is voluntary. However, if the information is not furnished, we may not be able to comply with your request. TO: VETERAN S ADMINISTRATION 4. MACRO-PRO, INCORPORATED, as Agents for P.O. BOX LONG BEACH, CA INFORMATION TO BE RELEASED: Copies of any and all Hospital Reports/Sum maries from to. Copies of the Outpatient Treatment Notes from Other. Please specify and give approximate treatment dates: NAME OF VETERAN ( type or print) 1) VA FILE NO. (include prefix) SOCIAL SECURITY NO. 2) 3) NAME AND ADDRESS OF ORGANIZATION, AGENCY OR INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED. VETERAN S REQUEST I hereby request and authorize the Veterans Administration to release the following information, from the records identified above to the organization, agency or individual named hereon: INFORMATION REQUESTED (Number each item requested and give the dates or approximate dates - period from and to - covered by each.) 5. Unless specified in #6, I authorize the release of the following information from my medical records, including drug, alcohol, psychiatric, sickle cell anemia, and HIV positive treatment information (or the history of such treatment). This information may be released by the V.A. to. If you are submitting an insurance form to be completed or need any other statement from your medical records, your chief complaint, treatment dates, diagnosis, operations and off-work dates if applicable from to IF THERE IS ANY INFORMATION THAT YOU DO NOT WANT RELEASED, PLEASE SPECIFY HERE: PURPOSE FOR WHICH THE INFORMATION IS TO BE USED: 7. Insurance Company Employer Disability Forms Other (Specify): Private Physician/Hospital 8. UNLESS OTHERWISE NOTED, THIS CONSENT WILL BE VALID FOR ONE (1) YEAR FROM THE DATE OF MY SIGNATURE. Note: Additional items of information may be listed on the reverse hereof. DATE SIGNATURE AND ADDRESS OF CLAIMANT, OR FIDUCIARY, IF CLAIMANT IS INCOMPETENT V A FORM VAFM95

20 OMB Number: Estimated Burden: 2 minutes REQUEST FOR AND AUTHORIZATION TO RELEASE MEDICAL RECORDS OR HEALTH INFORMATION Privacy Act and Paperwork Reduction Act Information: The execution of this form does not authorize the release of information other than that specifically described below. The information requested on this form is solicited under Title 38, U.S.C. The form authorizes release of information in accordance with the Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164, 5 U.S.C. 552a, and 38 U.S.C and 7332 that you specify. Your disclosure of the information requested on this form is voluntary. However, if the information including Social Security Number (SSN) (the SSN will be used to locate records for release) is not furnished completely and accurately, Department of Veterans Affairs will be unable to comply with the request. The Veterans Health Administration may not condition treatment, payment, enrollment or eligibility on signing the authorization. VA may disclose the information that you put on the form as permitted by law. VA may make a "routine use" disclosure of the information as outlined in the Privacy Act systems of records notices identified as 24VA19 Patient Medical Record - VA and in accordance with the VHA Notice of Privacy Practices. You do not have to provide the information to VA, but if you don't, VA will be unable to process your request and serve your medical needs. Failure to furnish the information will not have any affect on any other benefits to which you may be entitled. If you provide VA your Social Security Number, VA will use it to administer your VA benefits. VA may also use this information to identify veterans and persons claiming or receiving VA benefits and their records, and for other purposes authorized or required by law. The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 2 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. ENTER BELOW THE PATIENT'S NAME AND SOCIAL SECURITY NUMBER IF THE PATIENT DATA CARD IMPRINT IS NOT USED. TO: DEPARTMENT OF VETERANS AFFAIRS (Print or type name and address of health care facility) PATIENT NAME (Last, First, Middle Initial) SOCIAL SECURITY NUMBER NAME AND ADDRESS OF ORGANIZATION, INDIVIDUAL OR TITLE OF INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED VETERAN'S REQUEST: I request and authorize Department of Veterans Affairs to release the information specified below to the organization, or individual named on this request. I understand that the information to be released includes information regarding the following condition(s): DRUG ABUSE ALCOHOLISM OR ALCOHOL ABUSE TESTING FOR OR INFECTION WITH HUMAN IMMUNODEFICIENCY VIRUS (HIV) SlCKLE CELL ANEMIA INFORMATION REQUESTED (Check applicable box(es) and state the extent or nature of the information to be disclosed, giving the dates or approximate dates covered by each) COPY OF HOSPITAL SUMMARY COPY OF OUTPATIENT TREATMENT NOTE(S) OTHER (Specify) PURPOSE(S) OR NEED FOR WHICH THE INFORMATION IS TO BE USED BY INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED NOTE: ADDITIONAL ITEMS OF INFORMATION DESIRED MAY BE LISTED ON THE BACK OF THIS FORM AUTHORIZATION: I certify that this request has been made freely, voluntarily and without coercion and that the information given above is accurate and complete to the best of my knowledge. I understand that I will receive a copy of this form after I sign it. I may revoke this authorization, in writing, at any time except to the extent that action has already been taken to comply with it. Written revocation is effective upon receipt by the Release of Information Unit at the facility housing the records. Redisclosure of my medical records by those receiving the above authorized information may be accomplished without my further written authorization and may no longer be protected. Without my express revocation, the authorization will automatically expire: (1) upon satisfaction of the need for disclosure; (2) on (date supplied by patient); (3) under the following condition(s): I understand that the VA health care practitioner's opinions and statements are not official VA decisions regarding whether I will receive other VA benefits or, if I receive VA benefits, their amount. They may, however, be considered with other evidence when these decisions are made at a VA Regional Office that specializes in benefit decisions. DATE SIGNATURE OF PATIENT OR PERSON AUTHORIZED TO SIGN FOR PATIENT (Attach authority to sign, e.g., POA) FOR VA USE ONLY IMPRINT PATIENT DATA CARD (or enter Name, Address, Social Security Number) TYPE AND EXTENT OF MATERIAL RELEASED DATE RELEASED RELEASED BY VA FORM MAY USE EXISTING STOCK OF VA FORM , DATED NOV 2004.

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22 PATIENT NAME MEDICAL RECORD #: UNIVERSITY OF CALIFORNIA, DAVIS HEALTH SYSTEM AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION BIRTHDATE: Page 1 of 2 I authorize: Name of person and/or facility which has information Street Address, City, State, Zip Code to release health information to: Specify name/title of person and/or facility to receive health information Street Address, City, State, Zip Code *************************************************************************** Please specify the health information you authorize to be released: MEDICAL Type(s) of health information: Date(s) of treatment: MENTAL HEALTH (other than psychotherapy notes) You may also authorize the release of information for treatment provided after the date of the signature on this Authorization as long as such treatment occurs while this authorization has not expired. Please initial if you would like this Authorization to release information about healthcare you receive after the date of your signature. (Initial here) The following information will not be released unless you specifically authorize it by marking the relevant box(es) below: I specifically authorize the release of information pertaining to drug and alcohol abuse, diagnosis or treatment (42 C.F.R and 2.35). I specifically authorize the release of HIV/AIDS test results (Health and Safety Code (g)). I specifically authorize the release of genetic testing information (Health and Safety Code (j)) (1/09) AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PAGE 1 OF 2 MR#06/92192

23 PATIENT NAME MEDICAL RECORD #: UNIVERSITY OF CALIFORNIA, DAVIS HEALTH SYSTEM AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION BIRTHDATE: Page 2 of 2 The purpose of this release is for (check one or more): At the request of the patient/patient representative Other (state reason) NOTICE UCDHS and many other organizations and individuals such as physicians, hospitals and health plans are required by law to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may no longer be protected by state or federal confidentiality laws. YOUR RIGHTS This Authorization to release health information is voluntary. Treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this Authorization except in the following cases: (1) to conduct research-related treatment, (2) to obtain information in connection with eligibility or enrollment in a health plan, (3) to determine an entity s obligation to pay a claim, or (4) to create health information to provide to a third party. This Authorization may be revoked at any time. The revocation must be in writing, signed by you or your patient representative, and delivered to: Health Information Management Department, UCDHS, 2315 Stockton Blvd., Building 12, Sacramento, California The revocation will take effect when UCDHS receives it, except to the extent UCDHS or others have already relied on it. You are entitled to receive a copy of this Authorization. EXPIRATION OF AUTHORIZATION Unless otherwise revoked, this Authorization expires (insert applicable date or event). If no date is indicated, the Authorization will expire 12 months after the date of my signing this form. Print Name Signature (Patient, Parent, Representative) Date Time Relationship to Patient (Parent, Guardian, Conservator, Patient Representative) Witness (only if patient unable to sign) or Interpreter (1/09) AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PAGE 2 OF 2 MR#06/92192

24 AUTHORIZATION SECTION A: Individual authorizing use and/or disclosure. Name: Address: Telephone: Member Identification Number: SECTION B: The use and/or disclosure being authorized. PHI to Be Used and/or Disclosed: {Specifically describe the PHI to be used and/or disclosed} Check if this authorization is for psychotherapy notes. If this authorization is for psychotherapy notes, you must not use it as an authorization for any other type of protected health information (PHI). Entities or Persons Authorized to Use or Disclose: {Name or specifically describe the persons and/or organizations (or the classes of persons and/or organizations), including us, who are authorized to make use of and/or to disclose the PHI described above} Entities or Persons Authorized to Receive: {Name or specifically identify the persons and/or organizations (or the classes of persons and/or organizations), including us, who are authorized to receive, and subsequently use and/or disclose the PHI described above} Purpose of this Authorization: At request of individual. For the following purposes: No Conditions: This authorization is voluntary. We will not condition your enrollment in a health plan, eligibility for benefits or payment of claims on giving this authorization.

25 Effect of Granting this Authorization: The PHI used or disclosed may be subject to re-disclosure by the recipient, in which case it may no longer be protected under the HIPAA Privacy Rule. SECTION C: Expiration and revocation. Expiration: This authorization will expire (complete one): On / / On occurrence of the following event (which must relate to the individual or to the purpose of the use and/or disclosure being authorized): Right to Revoke: I understand that I may revoke this authorization at any time by giving written notice of my revocation to the Contact Office listed below. I understand that revocation of this authorization will not affect any action you took in reliance on this authorization before you received my written notice of revocation. Contact Office: Telephone: Address: Fax: INDIVIDUAL S SIGNATURE. I,, have had full opportunity to read and consider the contents of this authorization, and I understand that, by signing this form, I am confirming my authorization of the use and/or disclosure of my protected health information, as described in this form. Print Name: Signature: If this authorization is signed by a personal representative, i.e. with Legal Authority to act on behalf of the individual, complete the following: Personal Representative s Name: Date: Signature: Date: Relationship to Individual: YOU ARE ENTITLED TO A COPY OF THIS AUTHORIZATION AFTER YOU SIGN IT. Blue Cross of California and BC Life & Health Insurance Company are independent licensees of the Blue Cross Association (BCA). The Blue Cross name and symbol are registered service marks of the BCA.

26 INSTRUCTIONS FOR COMPLETION OF THE BLUE CROSS OF CALIFORNIA or BC Life & Health (BCC OR BC LIFE & HEALTH) GENERAL MEMBER AUTHORIZATION FORM Section A: Individual Authorizing Use and/or Disclosure Please complete all items of information in this section to include your Full Name and Member ID Number exactly as they appear on your Identification Card, your current address and a telephone number where you may be contacted. Section B: The Use and/or Disclosure Being Authorized Protected Health Information (PHI) to be Used and/or Disclosed: Enter the specific protected health information that you want used or disclosed. For example, if you want your claims processing, claims payment and enrollment information to be disclosed to a third party acting on your behalf, you may want to enter the following narrative in these spaces: "All information concerning claims payment, denial of coverage, the status of pending claims, billing status or any other information needed to respond to a normal customer service inquiry on my behalf" If Psychotherapy Notes is checked, authorization will be VOID for any and all other uses & disclosures. Entities or Persons Authorized to Use or Disclose: If you are authorizing BCC OR BC LIFE & HEALTH to disclose this information to another third party acting on your behalf, please enter the following in these spaces: "Blue Cross of California or BC Life & Health" Entities or Persons Authorized to Receive: Please enter the name(s) of the person(s) or organization(s) that you are authorizing to access your PHI and act on your behalf. For example, if you are authorizing your spouse or any other individual to act on your behalf, enter his/her name in these spaces. If you are authorizing an organization (such as a broker, consultant, or your company's Human Resources Department) to act on your behalf, enter the specific name of the organization in these spaces: Examples: "ABC broker" or "Human Resources Department, XYZ Company" These are example entries only. Please enter the actual names of the persons or organizations you are authorizing to receive PHI and act on your behalf. Purpose of this Authorization: There are two blocks in this section. Please complete only one of these blocks per the following instructions: If you check the "At request of individual" block, you are authorizing the person(s) or organization(s) you specified in the previous entry to receive your PHI and act on your behalf for any purpose permitted by the HIPAA Privacy Rule to include claims status and payment inquiries, appeals, premium payment inquiries and other policy service purposes. Checking this block is recommended because it will give your authorized representative and the BCC OR BC LIFE & HEALTH Customer Care Associates maximum flexibility to work together to respond to and resolve your policy service questions and needs. If you check this block, no further entries are required in this section. If you check the "For the following purposes:" block, you must enter a specific purpose for the authorization in the spaces provided. For example, if you only want the person(s) or organization(s) you are authorizing to receive your protected health information and act on your behalf to handle a claims appeal for you, you would enter "To appeal a claim determination" or something similar in that block. If you only want them to be able to check claims processing or payment status on your behalf, you would enter "To check claims processing or payment status" in that block. If you use this block, you need to know that BCC OR BC LIFE & HEALTH will only be able to discuss information pertaining to the purposes you specified with your authorized representative and nothing else.

27 Section C: Expiration and Revocation Expiration: There are two blocks in this section. Please complete only one of these blocks per the following instructions: If you want the authorization to expire on a certain date, please check the first block and enter that date in month, day and year order as specified (Example: 12/31/2004). If you enter a date in this space, no further entries are required in this section. If you want the authorization to expire when a future event occurs, please enter that event in the spaces provided for this block. An example entry is "Upon the end of my coverage with BCC OR BC LIFE & HEALTH." Right to Revoke: The contact office, telephone number, and address to be listed here, should reflect the Entities or Persons Authorized to Use or Disclose in Section B of the original Authorization form. If the entity indicated in Section B of the original Authorization form is BCC or BC LIFE & HEALTH, please enter the address and customer service telephone number listed on your identification card. Please make sure you complete one (but not both) of these blocks. Section D: Individual's Signature Please print your name in the first space and then sign and date it in the spaces provided. If your legal representative or guardian signs the form on your behalf, your legal representative or guardian must print his/her name, sign and date the form and indicate his/her relationship to you in the spaces provided. Please keep a copy of this authorization form for your records.

28 Authorization for Release of Personal & Health Information Blue Shield of California and/or Blue Shield of California Life & Health Insurance Company (Blue Shield) require specific written authorization for the disclosure of any personal and health information, beyond that which is necessary to provide treatment, to facilitate payment, or to perform operations of the health plan or insurer, to the extent permitted by law. Blue Shield will only disclose that information which is reasonably necessary to achieve the purpose of the request for release. 1. I, the Undersigned, Authorize: Blue Shield 2. To Release Information from the Records of: Member Name: Member Date of Birth: Subscriber #: 3. Information Authorized for Release (check all that apply): Address Change Policy or Contract Change Member/Dependent change PCP Change Dues Payment & Billing information Claims information Medical care and treatment Vision care and treatment Dental care and treatment Other (please specify) * If this authorization is for mental health, substance abuse, or HIV information, a separate completed authorization form will be necessary for the release of information (1) protected by the LPS Act or (2) containing HIV results. Further, the LPS Act often requires that both the patient s treating physician and the patient sign the authorization form before information may be released. 4. Information may be Released to: Name of individual or organization: Relationship: Name of individual or organization: Relationship: 5. Purpose & Limitations of the Authorization: By signing this form, you authorize the use and disclosure of the personal & health information above by a third party for the following purpose; please also list any limitations you would like to place on the use of this information: An Independent Member of the Blue Shield Association C15625 (1/10) blueshieldca.com

29 6. Signature You may refuse to sign this authorization. I,, have had full opportunity to read and consider the contents of this authorization. I understand that by signing this form, I am confirming my authorization that Blue Shield may use and/or disclose to the persons and/or organizations named in the information described in this form for the purposes stated. I understand that if the persons or organizations I authorize to receive and/or use the personal and health information described above are not health plans, covered health care providers or healthcare clearinghouses subject to federal health information privacy laws, they may further disclose the personal and health information and it may no longer be protected by federal health information privacy laws. Signature: Date: Print Name: 7. Expiration: This authorization will expire on: / / A specific date is required. If a date is not provided, then the authorization will expire one year from the signature date. Expiration and Revocation: This authorization will expire one year from the date of signature, or on the date you specify. If you sign this form, you may revoke the authorization at any time by notifying Blue Shield in writing at the address listed below. Revoking this authorization will not have any effect on actions that Blue Shield took in reliance on the authorization before we received the notification. Note: If this authorization is for a minor, the expiration date cannot exceed the 18th birthday of that minor. Treating Physician (signature may be necessary if related to mental health, substance abuse, or HIV care) Physician Signature: Date: Print Name: 8. Person or Entity Authorizing Disclosure of Information: If you are signing on behalf of the member, please indicate your relationship to the member and provide copies of verification of your legal right to authorize the disclosure of the member s personal and health information. Court Appointed Guardian, legal conservator, legal representative or Durable Power of Attorney for Health Care Spouse or person financially responsible Beneficiary or personal representative of deceased Parent or guardian of minor patient This authorization is voluntary. Blue Shield places no conditions on our payment activities in connection with your claims, your enrollment in a health plan or your eligibility for benefits because you have given this authorization. You may refuse to sign this authorization. You can request a copy of this authorization after you sign it. A copy of this authorization shall be considered as effective and valid as the original. Return completed authorization form to: Blue Shield of California, Attn: Customer Service, PO Box , Chico, CA H0504_09_342_ S2468_09_342_

30 Authorization for Disclosure of Private Health Information I hereby authorize CIGNA HealthCare*, its agents or subsidiaries to disclose the Private Health Information (PHI) indicated below to the persons or entities specified on this form. Please Note: This form is not required for all releases of your PHI. For example, this form may not be required to release information to: A spouse of a Member/Participant, when both are covered by the CIGNA HealthCare plan Parents of minors or other dependents Personal Representative on file with CIGNA HealthCare We will disclose certain PHI about you to these persons upon their request if they successfully complete a caller verification process. Please print your responses on this form. All sections must be completed for this authorization to be valid. VERIFICATION Identification of Member/Participant: (The following information is needed for verification.) Name of Member/Participant whose information will be disclosed: Date of Birth: Member/Participant Address: Phone number where we can reach you if we need to contact you to process your request (required): Social Security #: Member/Participant ID card # (if applicable): Group or Account # on ID card: Subscriber Name (if different from Member/Participant): Subscriber s Employer: Subscriber s Relationship to Member/Participant: Subscriber s Social Security # (if different from Member/Participant): If you have additional coverage with CIGNA, other than that which is described above, please provide the following information as well: Other Employer Name: Member/Participant ID Card #: Group or Account # on ID Card: Does this request apply to all coverage? Yes No Please Complete Next Page Page 1 of c 05/ CIGNA AUTH 2008

31 Description of Information to be Released Please indicate what information you wish to release by checking one or more of the boxes below. If you wish to grant limited access (i.e., specific dates of service, specific case management issues, etc.), please specify that in the space provided. Claims: Eligibility/Benefits: Medical Records: Case Management: Other: Unless otherwise indicated, my authorization includes the release of the following: (Please strike through those you wish to exclude, if any): Diagnosis and/or treatment for alcoholism and/or drug abuse or dependency Diagnosis and/or treatment of mental illness HIV antibody test results and/or AIDS diagnosis and treatment Genetic testing information Oklahoma Residents The information authorized for release may include records concerning a communicable or venereal disease, which may include, but are not limited to, diseases such as hepatitis, syphilis, gonorrhea and HIV/AIDS. You may have additional protections under Section of the Oklahoma Statutes if this type of information is to be released. Entity or Person Authorized to Receive Information: Name: Company (if applicable): Address of Individual or Company authorized to receive the information: Virginia Residents A copy of this authorization and a notation concerning the persons or agencies to whom disclosure was made shall be included with your original health records. Purpose of this release of information: Expiration of Authorization: This authorization expires: (date or event). If you state an event rather than a specific date, it will be necessary for you to submit a revocation form when the event occurs. Note for Members/Participants in the following states: If you live in Arizona, California, Georgia, Illinois, Massachusetts, Montana or Minnesota, your authorization will be valid for no more than one year. Authorizations signed by Virginia residents will be valid for no more than two years. Members/Participants living in those states who seek to authorize disclosure of their personal information for a longer period will have to submit a new authorization at the time that this authorization expires. Please Complete Next Page Page 2 of c 05/ CIGNA AUTH 2008

32 PLEASE NOTE Information disclosed based on this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations. If the information on this form is not complete, CIGNA HealthCare will return the form to you, and this request will not be considered until CIGNA HealthCare receives complete information. If your Member/Participant ID or date of birth is changed, another form will need to be completed at that time. If either the Member/Participant or Group changes to a different type of health care benefits coverage provided by CIGNA HealthCare, another form will need to be completed at that time. You may change or revoke this request by sending a written request to CIGNA HealthCare, Central HIPAA Unit, at the address below. You can obtain a Change/Revoke form by calling CIGNA HealthCare Member Services at the number on your CIGNA HealthCare ID card. The provision of treatment, payment enrollment or eligibility for benefits does not depend on whether you sign this authorization. I have read and understand the above information. My signature authorizes the disclosure of the information described. Signature of Member/Participant, Personal Representative, Parent/Guardian who is authorizing the Release: Date: Relationship if the person signing is other than Member/Participant whose information is to be used and disclosed: If this request is made by a Personal Representative, we will require verification of the authority of that Personal Representative before this request will be considered complete. If request is made by a Parent/Guardian, please complete the following: Member/Participant is a minor, years of age. If you are making this request on behalf of a minor child, we may require additional information before this request is considered complete. We recommend that you keep a copy of your completed form for your records. A copy will be retained by CIGNA HealthCare and made available upon your request. CIGNA, CIGNA HealthCare and the Tree of Life logo are registered service marks of CIGNA Intellectual Property, Inc., licensed for use by CIGNA Corporation and its operating subsidiaries. All products and services are provided exclusively by such operating subsidiaries and not by CIGNA Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Tel-Drug, Inc. and its affiliates, CIGNA Behavioral Health, Inc., Intracorp, and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc. In Arizona, HMO plans are offered by CIGNA HealthCare of Arizona, Inc. In California, HMO plans are offered by CIGNA HealthCare of California, Inc. and Great-West Healthcare of California, Inc. In Connecticut, HMO plans are offered by CIGNA HealthCare of Connecticut, Inc. In Virginia, HMO plans are offered by CIGNA HealthCare Mid-Atlantic, Inc. In North Carolina, HMO plans are offered by CIGNA HealthCare of North Carolina, Inc. All other medical plans in these states are insured or administered by Connecticut General Life Insurance Company. TO RETURN YOUR COMPLETED FORM Fax or Mail to: OR Mail to: CIGNA HealthCare Central HIPAA Unit, PO Box 5400, Scranton, PA Page 3 of c 05/ CIGNA AUTH 2008

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34 AUTHORIZATION FOR USE OR DISCLOSURE OF MEDICAL INFORMATION EXPLANATION This authorization for use or disclosure of medical information is being requested of you to comply with the terms of the federal HIPAA privacy regulations, 45 C.F.R AUTHORIZATION I hereby authorize [name of physician, hospital or health care provider] to furnish to Health Net medical records and information pertaining to [name of patient] This authorization is limited to the following medical records and type of information: USES Health Net may use the medical records and type of information authorized only for the following purposes: DURATION This authorization shall become effective immediately and shall remain in effect until [date]. NOTICE Information used or disclosed pursuant to an authorization may be subject to redisclosure by the recipient and no longer protected by the federal health information privacy regulations. MY RIGHTS I may revoke this authorization at any time as set forth in Health Net s Notice of Privacy Practices. Neither payment, enrollment nor eligibility for benefits will be conditioned on my providing or refusing to provide this authorization. This restriction does not apply if Health Net is seeking to

35 obtain information in connection with my eligibility or enrollment in Health Net when I am not already a member or to obtain information required for payment of a specific claim for benefits. I have a right to receive a copy of this authorization. SIGNATURE Date: Signature: [patient/representative/spouse/financially responsible party] If signed by other than patient, indicate relationship: Witness:

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38 STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF HEALTH CARE SERVICES PRIVACY OFFICE REQUEST FOR ACCESS TO PROTECTED HEALTH INFORMATION File Number: You have the right to inspect your protected health information in records, which Medi-Cal creates or maintains. You also have the right to request copies of those records. You will be charged for the costs of copying and mailing for some records. Fees are indicated below. You will receive a response to your request within 30 days after we receive your request and payment. If you want copies of your records mailed, you need to send us a photocopy of your California driver s license, Department of Motor Vehicles Identification Card, or other valid identification. You will also need to send documentation verifying your address. Checks should be made payable to the Department of Health Care Services (CDHS). Mail this completed form to: Department of Health Care Services EDS Communications P. O. Box Sacramento, CA (916) INDIVIDUAL INFORMATION LAST NAME FIRST NAME MIDDLE INITIAL ADDRESS CITY/STATE ZIP CODE BENEFITS ID NUMBER DATE OF BIRTH DAYTIME TELEPHONE NUMBER (Required) ( ) EVENING TELEPHONE NUMBER ( ) ADDRESS BEST HOURS TO REACH YOU DIRECTIONS Please read the following before completing this form. If any of the circumstances below applies to you, you may not need to fill out this form. You have a personal injury case and Medi-Cal has paid for services related to the injury and you want information about these services and/or payments, or You are requesting access to records on behalf of a deceased Medi-Cal beneficiary in order to repay Medi-Cal for services received by the deceased beneficiary. You may have received an Estate Recovery Questionnaire in the mail, or You are involved in a worker s compensation case in which Medi-Cal has paid for services for the injury you received while on the job. Please call (916) for further information. If none of these circumstances apply, please complete the form. To continue with your request for access to your Medi-Cal records, please go to page 2 and indicate which records you wish to get a copy of. Also, be sure to include the required information for verifying your identity and address, and include payment as indicated. DHCS 6236 (11/07) Page 1 of 3

39 STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF HEALTH CARE SERVICES PRIVACY OFFICE WHAT TYPE OF PROTECTED HEALTH INFORMATION DO YOU WANT TO ACCESS? CLAIM DETAIL REPORTS, which contain claims paid by Medi-Cal for services received. ($25 fee) TREATMENT AUTHORIZATION REQUEST SCREENS. Printouts contain patient names, which providers have requested services, which services were requested, the decision about the service(s), including a simple description of the decision, and whether the provider has billed for these services. CASE MANAGEMENT RECORDS, which contain case manager notes. Managed Care Records: Enrollment Records Disenrollment Records Capitation Paid to Health Plan Denti-Cal Records: Call (800) Please contact your managed care plan if you want access to your medical records. I AM REQUESTING COPIES OF RECORDS FOR THE FOLLOWING DATES OF SERVICE You must specify dates of service in order to get records. FROM DATE (month/day/year) TO DATE (month/day/year) Please note: A request for records of services provided up to 6 years ago is a 30-day process. All other requests have a 60-day time frame for additional processing. PLEASE MAIL ME A COPY OF THE REQUESTED INFORMATION. I WISH TO REVIEW THE REQUESTED INFORMATION IN PERSON. IF YOU REQUEST TO REVIEW RECORDS IN PERSON, YOU WILL BE CONTACTED TO SCHEDULE AN APPOINTMENT. LOCATION AVAILABLE FOR IN PERSON REVIEW: SACRAMENTO ONLY I REQUEST THAT A PERSON OF MY CHOOSING BE ALLOWED TO INSPECT MY RECORDS. NOTE: Any person or attorney may be named below. Records will not be sent to photocopy services. NAME TELEPHONE NUMBER ( ) ADDRESS RELATIONSHIP TO YOU DHCS 6236 (11/07) Page 2 of 3

40 STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF HEALTH CARE SERVICES PRIVACY OFFICE IDENTIFYING INFORMATION IS REQUIRED ADDRESS VERIFICATION ATTACHED TYPE: (UTILITY BILL, PHONE BILL, DRIVER S LICENSE, ETC.) COPY OF IDENTIFICATION ATTACHED TYPE: (CA DRIVER S LICENSE, CA DMV IDENTIFICATION CARD, BIRTH CERTIFICATE, BENEFITS IDENTIFICATION CARD, MANAGED CARE CARD, STATE OR FEDERAL EMPLOYEE ID CARD) NUMBER: (IF NO IDENTIFICATION IS ATTACHED, YOUR SIGNATURE MUST BE NOTARIZED.) NOTARIZED BY ON (DATE). NOTARY PUBLIC NUMBER UNOFFICIAL UNLESS STAMPED BY NOTARY PUBLIC. I DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION ON THIS FORM IS TRUE AND CORRECT. BENEFICIARY SIGNATURE DATE NOTE: ANY ATTEMPT TO FALSELY GAIN ACCESS TO PROTECTED HEALTH INFORMATION IS SUBJECT TO LEGAL PENALTIES. DHCS 6236 (11/07) Page 3 of 3

41 STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF HEALTH SERVICES PRIVACY OFFICE REQUEST TO ACCESS PROTECTED HEALTH INFORMATION BY PARENT, GUARDIAN OR PERSONAL REPRESENTATIVE File Number: As a parent, guardian, or personal representative you have the right to request to inspect the Medi-Cal records of the individual you are authorized to represent. You also have the right to request copies of the records. You will be charged for the cost of copying and postage for some records. You will receive a response to your request within 30 days after we receive your request and payment. If you want copies of your records mailed, you need to send us a photocopy of your California driver s license or other listed identification and documentation verifying your authority to represent the stated individual. You will also need to send documentation verifying your address, such as a utility bill displaying your address. Mail this completed form to: Department of Health Services EDS Communications P.O. Box Sacramento, CA (916) INDIVIDUAL WHOSE INFORMATION YOU ARE REQUESTING LAST NAME FIRST NAME MIDDLE INITIAL ADDRESS CITY/STATE ZIP CODE BENEFICIARY ID NUMBER DATE OF BIRTH DATE OF DEATH (If applicable) DEATH CERTIFICATE MUST BE ATTACHED DIRECTIONS Please read the following before completing this form. If any of the conditions set out below apply to the beneficiary you are requesting information about, you do not need to fill out this form. He/she has a personal injury case and Medi-Cal has paid for services related to the injury and you want information about these services and/or payments, or He/she is requesting access to records on behalf of a deceased Medi-Cal beneficiary in order to repay Medi-Cal for services received by the deceased beneficiary. He/she may have received an Estate Recovery Questionnaire in the mail, or He/She is involved in a worker s compensation case in which Medi-Cal has paid for services for the injury he/she received while on the job. To get information for a Medi-Cal beneficiary recovery case, please call (916) If the beneficiary is a member of a Medi-Cal Managed Care Plan, please contact his/her plan for access to his/her medical records. DHS 6237 (1/06) Page 1 of 3

42 STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF HEALTH SERVICES PRIVACY OFFICE PARENT, GUARDIAN, OR PERSONAL REPRESENTATIVE INFORMATION LAST NAME: FIRST NAME: MIDDLE INITIAL: ADDRESS: CITY/STATE: ZIP CODE: DAYTIME TELEPHONE NUMBER (Required): ( ) EVENING TELEPHONE NUMBER: ( ) ADDRESS: BEST HOURS TO REACH YOU: WHAT LEGAL AUTHORITY DO YOU HAVE TO REQUEST HEALTH INFORMATION OF THE INDIVIDUAL ABOVE? PARENT GUARDIAN MEDICAL POWER OF ATTORNEY CONSERVATOR EXECUTOR OF WILL OTHER PLEASE ATTACH LEGAL DOCUMENTATION VERIFYING THAT YOU ARE THE PARENT, CONSERVATOR, GUARDIAN, EXECUTOR OF A DECEDENT S WILL, OR HAVE MEDICAL DECISION-MAKING AUTHORITY FOR THE INDIVIDUAL. PROTECTED HEALTH INFORMATION YOU WANT TO ACCESS WHAT TYPE OF PROTECTED HEALTH INFORMATION DO YOU WANT TO ACCESS? CLAIM DETAIL REPORTS, which show claims paid by Medi- Cal for services received. ($25 fee) TREATMENT AUTHORIZATION REQUEST SCREENS. Printouts show which providers have requested services, which services were requested, the decision about the service(s), including a simple description of the decision, and whether the provider has billed for these services. (No fee) CASE MANAGEMENT RECORDS, which show case manager notes. (No fee) Managed Care Records: Enrollment Records Disenrollment Records Capitation Paid to Health Plan Complaint investigation files (No fee) Please contact your managed care plan if you want access to your medical records. Other, please specify: FROM DATE FOR WHAT TIME PERIOD DO YOU WANT INFORMATION? TO DATE DHS 6237 (1/06) Page 2 of 3

43 STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF HEALTH SERVICES PRIVACY OFFICE METHOD TO ACCESS YOUR PROTECTED HEALTH INFORMATION PLEASE MAIL ME A COPY OF THE REQUESTED INFORMATION. I WISH TO REVIEW THE REQUESTED INFORMATION IN PERSON. I REQUEST THAT A PERSON OF MY CHOOSING BE ALLOWED TO INSPECT MY RECORDS. NOTE: Any person or attorney may be named below. Records will not be sent to photocopy services. NAME: TELEPHONE NUMBER: ( ) ADDRESS: RELATIONSHIP TO YOU: IF YOU REQUEST TO REVIEW RECORDS IN PERSON, YOU WILL BE CONTACTED TO SCHEDULE AN APPOINTMENT. LOCATION AVAILABLE FOR IN PERSON REVIEW: SACRAMENTO ONLY COPY OF IDENTIFICATION ATTACHED IDENTIFYING INFORMATION TYPE (CA DRIVER S LICENSE, CA DMV IDENTIFICATION CARD, BIRTH CERTIFICATE, BENEFICIARY IDENTIFICATION CARD, MANAGED CARE CARD, STATE OR FEDERAL EMPLOYEE ID CARD) NUMBER: I DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION ON THIS FORM IS TRUE AND CORRECT. REPRESENTATIVE SIGNATURE: DATE: (IF NO IDENTIFICATION IS ATTACHED YOUR SIGNATURE MUST BE NOTARIZED.) NOTARIZED BY ON (DATE) NOTARY PUBLIC NUMBER: UNOFFICIAL UNLESS STAMPED BY NOTARY PUBLIC: ADDRESS VERIFICATION ATTACHED FORM OF ADDRESS VERIFICATION (UTILITY BILL, PHONE BILL, DRIVER S LICENSE, ETC.) NOTE: ANY ATTEMPT TO FALSELY GAIN ACCESS TO PROTECTED HEALTH INFORMATION IS SUBJECT TO LEGAL PENALTIES. DHS 6237 (1/06) Page 3 of 3

44 AUTHORIZATION FOR RELEASE OF RECORDS TO: EMPLOYMENT DEVELOPMENT DEPARTMENT I,, authorize the Employment Development (type or print name) Department (EDD) to release a copy of the following records pertaining to myself,, covering the period (specify type of record, see below) from to to the following individual or (month/day/year) (month/day/year) entity: Name Address City, State, Zip Code This Authorization shall remain in effect for 90 days from the date below or until. (month/day/year) A copy or facsimile of this Authorization shall be as valid as the original. Date: Signature: Social Security Number: Types of records maintained by EDD: Unemployment Insurance State Disability Insurance Job Service Wages Reported by Quarter (The disclosure of your social security number is voluntary. However, since most EDD records are filed by social security number, EDD may be unable to locate any or all of the records requested without disclosure of your social security number.)

45 Authorization for Release Of Health Information UCLA Form #30910 Rev. (10/08) Page 1 of 2

46 : UCLA Form #30910 Rev. (10/08) Page 2 of 2

47 AUTHORIZATION FOR DISCLOSURE OF MEDICAL OR DENTAL INFORMATION PRIVACY ACT STATEMENT In accordance with the Privacy Act of 1974 (Public Law ), the notice informs you of the purpose of the form and how it will be used. Please read it carefully. AUTHORITY: Public Law ; E.O (SSAN); DoD R. PRINCIPAL PURPOSE(S): This form is to provide the Military Treatment Facility/Dental Treatment Facility/TRICARE Health Plan with a means to request the use and/or disclosure of an individual's protected health information. ROUTINE USE(S): To any third party or the individual upon authorization for the disclosure from the individual for: personal use; insurance; continued medical care; school; legal; retirement/separation; or other reasons. DISCLOSURE: Voluntary. Failure to sign the authorization form will result in the non-release of the protected health information. This form will not be used for the authorization to disclose alcohol or drug abuse patient information from medical records or for authorization to disclose information from records of an alcohol or drug abuse treatment program. In addition, any use as an authorization to use or disclose psychotherapy notes may not be combined with another authorization except one to use or disclose psychotherapy notes. SECTION I - PATIENT DATA 1. NAME (Last, First, Middle Initial) 2. DATE OF BIRTH (YYYYMMDD) 3. SOCIAL SECURITY NUMBER 4. PERIOD OF TREATMENT: FROM - TO (YYYYMMDD) 5. TYPE OF TREATMENT (X one) OUTPATIENT INPATIENT BOTH SECTION II - DISCLOSURE 6. I AUTHORIZE TO RELEASE MY PATIENT INFORMATION TO: (Name of Facility/TRICARE Health Plan) a. NAME OF PHYSICIAN, FACILITY, OR TRICARE HEALTH PLAN b. ADDRESS (Street, City, State and ZIP Code) c. TELEPHONE (Include Area Code) d. FAX (Include Area Code) 7. REASON FOR REQUEST/USE OF MEDICAL INFORMATION (X as applicable) PERSONAL USE INSURANCE CONTINUED MEDICAL CARE RETIREMENT/SEPARATION SCHOOL LEGAL 8. INFORMATION TO BE RELEASED OTHER (Specify) 9. AUTHORIZATION START DATE (YYYYMMDD) 10. AUTHORIZATION EXPIRATION DATE (YYYYMMDD) ACTION COMPLETED SECTION III - RELEASE AUTHORIZATION I understand that: a. I have the right to revoke this authorization at any time. My revocation must be in writing and provided to the facility where my medical records are kept or to the TMA Privacy Officer if this is an authorization for information possessed by the TRICARE Health Plan rather than an MTF or DTF. I am aware that if I later revoke this authorization, the person(s) I herein name will have used and/or disclosed my protected information on the basis of this authorization. b. If I authorize my protected health information to be disclosed to someone who is not required to comply with federal privacy protection regulations, then such information may be re-disclosed and would no longer be protected. c. I have a right to inspect and receive a copy of my own protected health information to be used or disclosed, in accordance with the requirements of the federal privacy protection regulations found in the Privacy Act and 45 CFR s d. The Military Health System (which includes the TRICARE Health Plan) may not condition treatment in MTFs/DTFs, payment by the TRICARE Health Plan, enrollment in the TRICARE Health Plan or eligibility for TRICARE Health Plan benefits on failure to obtain this authorization. I request and authorize the named provider/treatment facility/tricare Health Plan to release the information described above to the named individual/organization indicated. 11. SIGNATURE OF PATIENT/PARENT/LEGAL REPRESENTATIVE 12. RELATIONSHIP TO PATIENT (If applicable) 13. DATE (YYYYMMDD) SECTION IV - FOR STAFF USE ONLY (To be completed only upon receipt of written revocation) 14. X IF APPLICABLE: AUTHORIZATION REVOKED 15. REVOCATION COMPLETED BY 16. DATE (YYYYMMDD) 17. IMPRINT OF PATIENT IDENTIFICATION PLATE WHEN AVAILABLE DD FORM 2870, DEC 2003 SPONSOR NAME: SPONSOR RANK: FMP/SPONSOR SSN: BRANCH OF SERVICE: PHONE NUMBER:

48 AUTORIZACIÓN PARA OBTENER DOCUMENTOS MEDICOS, EMPLEO, SEGURO SOCIAL, EDUCACIONALES Y ASEGURANZAS (Authorization for the release of Medical, Employment, Social Security, Scholastic and Insurance Records) Página 1 de 2 (Page 1 of 2) Yo autorizo (I authorize): Nombre de entidad con expedientes/entidad autorizada (Name of Facility with Records/Disclosing Party) Que entreguen a (To disclose to): Nombre de la parte que solicita, aseguranza, y/o sus abogados, mediante Macro-Pro, Inc., su agente, a revisar, inspeccionar, y/o fotocopiar Alguno y todos los documentos médicos, que incluya pero no se limite a: Archivos médicos, reportes, cedulas, graficas, notas, exámenes, rayos x s, MRI s, cuentas medicas, y reportes. (Any and all medical records, to include but not limited to: Medical files, reports, charts, graphs, notes, tests, x-rays, MRI s, Billings and laboratory reports.) Con mis iniciales en esta linea, yo autorizo el obtenimiento de información concerniente a exámenes, diagnósticos, y tratamiento del HIV y/o SIDA. (By initialing this line, I hereby authorize the release of information concerning the testing, diagnosis and treatment for HIV and/or AIDS.) Alguno y todos los documentos de empleo, que incluya a pero no se limite a: Archivo personal, documentos de asistencia, empleo documentos, documentos de médicos y de aseguranza y archivos de salario. (Any and all employment and/or union records, to include but not limited to: Personnel file, attendance records, employment records, medical and insurance records, pension Benefit records and wage records.) Alguno y todos los documentos archivos médicos de la Administración del Seguro Social. (Any and all medical records from the Social Security Administration.) Alguno y todos los archivos escolares, que incluya a pero no se limite a: asistencia, archivos acerca o infracciones, archivos médicos y transcripciones. (Any and all scholastic records, to include but not limited to: Attendance records, records regarding any disciplinary action or infractions, medical records and transcripts.) Alguno y todos los archivos de reclamos de aseguranza, que incluya a pero no se limite a: del firmante relacionado con el pasado, presente y reclamos subsecuentes por daños y/o perjuicios. (Any and all insurance claim files for the undersigned dealing with prior, present and subsequent claims for injuries and/or damages.) El solicitante puede usar la información de salud autorizada en esta forma para el siguiente propósito solamente (The requestor may use the health information on this form for the following purposes only): AUTHORIZACIÓN 2 ESPANOL 2003-HIPAA (English translation in italics) Page 1 of 2

49 AUTORIZACIÓN PARA OBTENER DOCUMENTOS MEDICOS, EMPLEO, SEGURO SOCIAL, EDUCACIONALES Y ASEGURANZAS (Authorization for the release of Medical, Employment, Social Security, Scholastic and Insurance Records) Página 2 de 2 (Page 2 of 2) DURACION : Esta autorización entrará en vigencia inmediatamente y se mantendrá vigente hasta ó UN ano desde la dia que se firmo. DURATION: This authorization shall become effective immediately and shall remain in effect until < date > or for ONE full year from date of signature. REVOCACION: Esta autorización esta también sujeta a ser revocada por escrito por el que firma a cualquier momento entre ahora y la entrega de información por la entidad que la entrega. Mi revocación escrita entrara en vigencia cuando es recibida pero no se extenderá a lo que el pedidor ó otros han actuado basándose en esta autorización. REVOCATION: This authorization is also subject to written revocation by the undersigned at any time between now and the disclosure of information by the disclosing party. My written revocation will be effective upon receipt but will not be effective to the extent that the requestor or others have acted in reliance upon this authorization. RE-ENTREGAR: Yo entiendo que el pedidor no puede por ley hacer uso ó entregar la información de salud a menos que otra autorización es obtenida de mi ó al menos que el uso ó entrega es específicamente requerido o permitido por la ley. REDISCLOSURE: I understand that the requester may not lawfully further use or disclose the health information unless another authorization is obtained from me or unless such use or disclosure is specifically required or permitted by law. Yo entiendo que tengo el derecho de recibir una copia de esta autorización. Una copia de esta autorización será considerada tan valida como la original. (I understand that I have the right to receive a copy of this authorization. A copy of this authorization shall be considered as valid as original.) Firma Escriba su nombre Fecha AUTHORIZACIÓN 2 ESPANOL 2003-HIPAA (English translation in italics) Page 2 of 2

50 AUTORIZACIÓN PARA OBTENER INFORMACIÓN MEDICA (Authorization for Release of Medical Information) Página 1 de 2 (Page 1 of 2) Yo autorizo (I authorize): Nombre de la entidad con expedientes/entidad autorizada (Name of Facility with Records/Disclosing Party) Que entreguen a (To disclose to): Nombre de la parte que solicita, aseguranza, y/o sus abogados, mediante Macro-Pro, Inc., su agente, a revisar, inspeccionar, y/o fotocopiar Documentos e información perteneciente a (Documents and information pertaining to): Nombre del Paciente - Enumere otros nombres usados (Name of Patient List Other Names Used) Domicilio (Address) Fecha de nacimiento (Date of Birth) Numero de teléfono durante el dia (Daytime Telephone Number) DURACION: Esta autorización entrará en vigencia inmediatamente y se mantendrá vigente hasta ó UN año desde la dia que se firmo. DURATION: This authorization shall become effective immediately and shall remain in effect until < date > or for ONE full year from date of signature. REVOCACION: Esta autorización esta también sujeta a ser revocada por escrito por el que firma a cualquier momento entre ahora y la entrega de información por la entidad que la entrega. Mi revocación escrita será efectiva cuando es recibida pero no se extenderá a lo que el pedidor ó otros han actuado basándose en esta autorización. REVOCATION: This authorization is also subject to written revocation by the undersigned at any time between now and the disclosure of information by the disclosing party. My written revocation will be effective upon receipt but will not be effective to the extent that the requestor or others have acted in reliance upon this authorization. RE-ENTREGAR: Yo entiendo que el pedidor no puede por ley hacer usa ó entregar la información de salud a menos que otra autorización es obtenida de mi ó al menos que el uso ó entrega es específicamente requerido o permitido por la ley. REDISCLOSURE: I understand that the requester may not lawfully further use or disclose the health information unless another authorization is obtained from me or unless such use or disclosure is specifically required or permitted by law. AUTHORIZACIÓN ESPANOL 2003-HIPAA (English translation in italics) Page 1 of 2

51 AUTORIZACIÓN PARA OBTENER INFORMACIÓN MEDICA (Authorization for Release of Medical Information) Página 2 de 2 (Page 2 of 2) ESPECIFIQUE LOS DOCUMENTOS A OBTENER (SPECIFY DOCUMENTS TO OBTAIN): Marque las casillas e iniciales/firme para especificar que tipo de información debe ser entregada. (Mark the boxes and initial to specify records to be disclosed.) INFORMACIÓN MEDICA (Medical Information): Iniciales INFORMACIÓN PSYCHIATRICA (Psychiatric Information): Firma (Signature) Fecha (Date) CUENTAS MÉDICA (Medical Billing): Iniciales INFORMACIÓN DE DROGAS/ALCOHOL (Drug/Alcohol Information): Firma (Signature) Fecha (Date) RAYOS Y RADIOGRAFIAS (X-Rays and Films): Iniciales HIV/SIDA EXÁMENES, DIAGNOSTICOS, TRATAMIENTOS (HIV/Aids Testing, Diagnosis & Treatment) Firma (Signature) Fecha (Date) OTRA INFORMACIÓN DE SALUD QUE SERA ENTREGADA (Other health information to be disclosed): El solicitante puede usar la información de salud autorizada en esta forma para el siguiente propósito solamente (The requestor may use the health information authorized on this form for the following purposes only): Yo entiendo que tengo el derecho de recibir una copia de esta autorización. Una copia de esta autorización será considerada tan valida como la original. (I understand that I have the right to receive a copy of this authorization. A copy of this authorization shall be considered as valid as original.) Firma Escriba su nombre Fecha AUTHORIZACIÓN ESPANOL 2003-HIPAA (English translation in italics) Page 2 of 2