Forms

Read about downloading files.

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

Notice of Privacy Practices (NPP)

Description English Farsi Spanish Vietnamese
Notice of Privacy Practices (NPP) 
This is the County NPP given to patients/clients at the first delivery of medical treatment services.
English PDF version of County Notice of Privacy Practices Farsi PDF version of County Notice of Privacy Practices Spanish PDF version of County Notice of Privacy Practices Vietnamese PDF version of County Notice of Privacy Practices

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. Fact sheet & Complaint Form in PDF Fact sheet & Complaint Form in Word
View the online form.

HIPAA Downloads

Description Form
Authorization to Use and Disclose Protected Health Information (PHI) - This authorization form will be used by our clients to initiate a request to have their PHI disclosed outside of HCA or between Programs with sensitive confidentiality requirements. PHI Form in PDF PHI Form in Word
Revocation of Authorization to Use or Disclose Protected Health Information - This form is now required under HIPAA. If the client/patient wants to revoke an authorization, it must be done in writing and will be processed through the HCA/Custodian of Records office.
Instructions available in Word or PDF format.
Revocation of Authorization Form in PDF
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.