Authorization for Use or Disclosure of Medical Information

For our patients convenience the District's Authorization for Use or Disclosure of Medical Information form is available for printing out and completion. It can then be faxed back to the District at the fax number on page two of the form.

Authorization for Use or Disclosure of Medical Information form

If you would like to report a HIPAA Privacy-Security Violation, please fill out this form:
HIPPA Violation Form
     Complete this form as accurately as possible. Hand-deliver, email or fax your completed form and any supporting documents including those documents retrieved from the entity that received the inappropriate documentation to Elizabeth Rosales, Privacy Officer, elizabeth.rosales@jcf-hospital.com or FAX:(209) 225-2388.
     Also please upload and save the same documents to the Symplr application specific
event within Symplr (contact Quality for instructions ext 5055 or 5056).