Click on the icon, in the table below, to download the appropriate file.
Notice of Privacy Practices (NPP)
Notice of Privacy Practices (NPP) – Provider This is the County NPP given to patients/clients at the first delivery of medical treatment services.
Notice of Privacy Practices (NPP) – Health Plan This is the Health Care Agency NPP mailed to patients/clients provided medical benefits under an HCA supported health plan (such as CCS, MSI, CTU).
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.
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.
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.
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.