How to Fill Out the Health Plan of San Joaquin Authorization Form

To let someone else see your protected health information, use the Health Plan of San Joaquin authorization form titled “Member Authorizations for Use and Disclosure of PHI.” You download it from the plan’s website, fill in every section by hand, sign it, and return the paper form by mail or fax to the plan’s French Camp office. Both federal HIPAA rules and California’s Confidentiality of Medical Information Act dictate what the form must contain, and HPSJ treats an incomplete form as invalid.1Health Plan of San Joaquin. HIPAA Member Forms

Where to Download the Form

The form lives on HPSJ’s HIPAA member forms page at hpsj.com/hipaa-member-forms. Look for “Member Authorizations for Use and Disclosure of PHI.” A large-print version is posted alongside the standard version.

The form cannot be completed online or signed digitally. HPSJ’s site states clearly that each form must be printed and filled out on paper. If you scan a completed paper form and email it, there is no indication the plan will accept that method, so plan on mail or fax from the start.1Health Plan of San Joaquin. HIPAA Member Forms

What to Have Ready Before You Start

Every HIPAA-compliant authorization has to contain certain core elements. Missing any one of them gives the plan grounds to reject your form, so gather this information before you pick up a pen:

  • Your HPSJ member ID number.
  • The full name and mailing address of the person or organization that will receive your records.
  • A specific description of the information you want shared. “All records from January 2025 through June 2025” works. “Mental health treatment records only” works. “Everything, forever” does not.
  • The purpose of the release. If you are the one asking for it, “at the request of the member” is enough.
  • An expiration date or triggering event. You might write a calendar date or something like “upon resolution of my disability claim.”
  • Your signature and the date you sign.

These are the minimum elements required by 45 CFR 164.508(c)(1).2eCFR. 45 CFR 164.508 – Uses and Disclosures for Which an Authorization Is Required

California Rules That Catch People Out

California’s Confidentiality of Medical Information Act adds requirements on top of HIPAA. Civil Code Section 56.11 says the authorization must be in at least 14-point type, must have a signature line clearly separate from any other text, must identify both the entity disclosing and the entity receiving the information, and must state any limits on how the recipient can use the information. The expiration generally cannot run more than one year unless you specifically request a longer period.3California Legislative Information. California Code, Civil Code CIV 56.11

HPSJ’s printed form is built to satisfy both federal and state rules, so if you complete every field as printed, you should be covered. The risk is leaving a field blank or writing something vague.

Sensitive Information Checkboxes

Mental health treatment records, substance abuse treatment records, and HIV-related test results each have their own disclosure rules under California law. HPSJ’s authorization form includes separate checkboxes or initial lines for these categories, and you have to affirmatively opt in to release each one. Checking the general “all medical records” box does not release them.

If you skip the mental health checkbox, those records stay private even when you have authorized everything else. The categories are broken out this way because state law prohibits bundling sensitive data into a blanket release without explicit, category-specific consent.

Signing on Behalf of Someone Else

Minors

A parent or legal guardian is generally the child’s personal representative under HIPAA and can authorize disclosure of the child’s records.4U.S. Department of Health and Human Services. Personal Representatives and Minors California carves out an important exception. Minors aged 12 and older can consent on their own to certain services, including sexual and reproductive healthcare, mental health counseling, and drug and alcohol treatment.5California School-Based Health Alliance. Consent When care falls under one of those consent provisions, the provider must keep the information confidential from the parent, and a parent’s authorization cannot override that.

In practice, if your teenager received counseling they consented to on their own, you cannot use this form to reach those specific records. The minor would need to sign their own authorization for that subset.

Personal Representatives

Someone other than the member can sign if they are the member’s legally recognized personal representative. The documents that establish this include a health care power of attorney, a court-appointed guardianship or conservatorship, or a durable power of attorney that expressly covers health care decisions.

If the representative’s authority is limited to a specific condition, they can only access health information within that scope.6U.S. Department of Health and Human Services. Guidance: Personal Representatives A personal representative signing the HPSJ form needs to describe their legal authority on the form itself and attach a copy of the supporting document. The plan verifies the representative’s authority before processing the release.

How to Submit the Completed Form

Once the form is filled in and signed, HPSJ gives you two primary ways to return it:

You can also hand-deliver the form to the French Camp office. Faxing is the fastest route. Whichever channel you use, keep a copy of the signed form. If there is ever a question about what you authorized, that copy is your proof.

What Happens After You Submit

HPSJ staff check that all required elements are present and the signature is authentic. A complete form is recorded, and the designated recipient can then request your records. If something is missing or the signature does not match plan records, the plan contacts you and the authorization does not take effect until the problem is fixed.

If you have not heard anything after a few weeks, call HPSJ Customer Service at 1-888-936-7526 (Medi-Cal) or 1-888-361-7526 (D-SNP) to check status.7Health Plan of San Joaquin. Notice of Privacy Practices

How to Cancel an Authorization Later

You can revoke any authorization at any time, for any reason. HPSJ posts a separate “Authorization to Revoke a Previous Authorization” form on the same HIPAA member forms page. It asks for your identifying details and a clear statement of which prior authorization you are withdrawing.8Health Plan of San Joaquin. Authorization to Revoke a Previous Authorization

Return the revocation by mail to the French Camp address, by fax to 1-209-461-2550, or by hand delivery. HPSJ also has an office at 1025 J Street, Modesto, CA 95354 that accepts hand-delivered forms. The revocation takes effect on the date the plan receives it. It does not undo disclosures that already happened while the original authorization was valid.9U.S. Department of Health and Human Services. Can an Individual Revoke His or Her Authorization If records were shared with a third party last week and you fax your revocation today, last week’s disclosure still stands. From the date HPSJ receives the revocation, no further releases happen under that authorization.

The revocation form itself has to be filled out completely and signed. A blank field or missing signature means the original authorization stays in force.