Forms

The Notice of Privacy Practices (NPP) notice describes how health information about you may be used and disclosed in the Orange County Health Care Agency and your rights regarding use of that information.

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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 Farsi
Notice of Privacy Practices (NPP) - Provider - This is the County NPP given to patients/clients at the first delivery of medical treatment services. updated English 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 Farsi PDF version of County Notice of Privacy Practices
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, MHP, CHDP).
PDF version of Notice of Privacy Practices Employee Benefits Spanish PDF version of Notice of Privacy Practices Employee Benefits Vietnamese PDF version of Notice of Privacy Practices Employee Benefits  

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

English

Farsi

Spanish

Vietnamese

Authorization to Use and Disclose Protected Health Information (PHI) - This authorization form is used by County of Orange clients to request a copy of their medical information or to request that their medical information be released to another health care provider. PHI Form in PDF PHI Form in Word

PHI Form in PDF PHI Form in Word

PHI Form in PDF PHI Form in Word

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 Custodian of Records office. Instructions available in Word or PDF format. Revocation of Authorization Form in PDF