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H�R��Pp�uV�r�u0 ~ | H�R��Pp�uV�r�u0 ~ 5/2020) WWW Page 1 of 5 A Public Service Agency DRIVER MEDICAL EVALUATION (Medical information is CONFIDENTIAL under California Vehicle Code §1808.5 CVC) INSTRUCTIONS TO THE DRIVER: Please take this form to the medical professional most familiar with your health history and current medical condition. Tiếng Việt, About Us | Step 1 – Download in Adobe PDF.
release the following health information: To: The whole file contains two pages, and each page needs the signature. Every part is brief but clear.
endstream endobj 284 0 obj <>/ProcSet[/PDF]>>>> stream This template begins with the introduction and instruction, and then nine parts compose into this file. C���3��2Wj&=2`��30�}�@o� �/+� At the end of the file, it requires the signature of the concerned person or his representative/guardian and witness. DEPARTMENT OF HEALTH CARE SERVICES PRIVACY OFFICE .
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If you need to install or upgrade to the latest version, click the “, Health Insurance Premium Program (HIPP) Application, Dental, Request for Access to Protected Health Information, Solicitud Para El Programa De Pago De Primas De Seguro De Salud, Aviso De Posible Responsabilidad De Terceros, Access Health Care Language Assistance Services (SB 223). |
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION .
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