County of Orange: Health Insurance Portability & Accountability Act

County of Orange > Health Care Agency

County Home

HIPAA Privacy Officer
(714) 834-5172

Security Officer
(714) 834-6798

HCA/HIPAA Coordinator
BLDG. 38 Suite 676
(714) 834-4082
(714) 834-6595 fax

Download Forms

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Click on the icon, in the table below, to download the appropriate file.

Notice of Privacy Practices (NPP)

Description
English
Spanish
Vietnamese

Notice of Privacy Practices (NPP) - Provider & Health Plan - This is the County NPP given to clients at the first delivery of medical services and/or mailed to clients who receive medical benefits under an HCA supported health plan (such as CCS, MSI, CTU)

Complaint Form

Description
Download

Complaint Filing Form & Fact Sheet - The HIPAA Privacy Rule allows you to make a complaint regarding violation of your privacy rights by a covered entity. If you believe that a person, agency or program covered under HIPAA violated your or someone else's health information privacy rights, or committed another violation of the Privacy Rule, you may file a complaint with the County of Orange HIPAA Privacy Officer.

Click here for online version of Form

HIPAA Downloads

Description
Form

Authorization to Use and Disclose Protected Health Information (PHI) - This authorization form is used by County of Orange clients to request to have their PHI disclosed outside of HCA, or between Programs with sensitive confidentiality requirements.

Revocation of Authorization to Use or Disclose Protected Health Information -This form is required under HIPAA. If a County of Orange client/patient wants to revoke an authorization, it must be done in writing and will be processed through the Custodian of Records office.

Instructions

Request for Special Restriction on the Use or Disclosure of PHI – This form is used by a County of Orange client/patient to request restrictions on use/disclosure of their PHI.

Termination of Special Restriction – This form is to be completed by client/patient or by Program to communicate and document the termination of restrictions on PHI.

Request for Restriction on the Manner/Method of Confidential Communications – This form is used by a County of Orange client/patient to request alternative method of communication of their PHI.

Request to Amend PHI – This form is used by a County of Orange client/patient to request an amendment to their PHI.

Statement of Disagreement/Request to Include Amendment Request and Denial with Future Disclosure

Request for an Accounting of Disclosures - This form is required under HIPAA, and is used by a County of Orange client/patient to request an accounting of disclosures.