County of Los Angeles, Department of Public Health 2026

1. Click ‘Get Form’ to open the County of Los Angeles, Department of Public Health form in the editor.
2. Begin by filling out your personal information in Section I. Enter your name (Last, First, Middle), date of birth, address, Medi-Cal or My Health LA number, and phone number.
3. In Section II, choose between Option 1 or Option 2 for sharing health information. If you select Option 2, list the specific providers authorized to share your information.
4. Proceed to Section III and specify the scope of disclosure. Check all relevant boxes indicating what type of health information can be shared.
5. In Section IV, indicate the expiration date for this authorization. This can be a specific date or one year from the execution date.
6. Review Section V for important information regarding your rights and protections under federal regulations before signing in Section VI.
7. Complete Sections VII and VIII if you wish to revoke authorization or understand prohibitions on redisclosure.

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