Fill and Sign the Gc 333 Ex Parte Application for Order Authorizing Completion Form

CASE NUMBER: EX PARTE ORDER AUTHORIZING DISCLOSURE OF (PROPOSED) CONSERVATEE' S HEALTH INFORMATION TO COURT INVESTIGATOR—HIPAA (Probate—Guardianships and Conservatorships) SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: GC-336 FOR COURT USE ONLY CONSERVATORSHIP OF THE PERSON ESTATE OF (PROPOSED) CONSERVATEE 1. Page 1 of 2 Form Adopted for Mandatory Use Judicial Council of California GC-336 [New January 1, 2009] Civil Code, § 56.10; Probate Code, §§ 1801, 1821, 1826; 42 U.S.C. §§ 1177, 1178; 45 C.F.R. §§ 160 and 164 3. 2. To perform the investigations required by law, the court invest igator or investigators named in item 3 must have access to protected health information about the (proposed) conservatee named in the caption above. THE COURT FINDS (Name): 5. 4. EX PARTE ORDER AUTHORIZING DISCLOSURE OF (PROPOSED) CONSERVATEE' S HEALTH INFORMATION TO COURT INVESTIGATOR—HIPAA (Health Insurance Portability and Accountability Act of 1996) Each health-care provider, health plan, and health-care clearin ghouse that has protected health-care information about the (proposed) conservatee named above is authorized to disclose the information to any court investigator named in item 3. THE COURT ORDERS Notice is dispensed with. The court investigators authorized to access the (proposed) conservatee's protected health information are (name each authorized court investigator): 7. Additional orders, the judicial officer's signature, and the date of this order are on the next page. The protected health information must be used by the court investigator solely to discharge the investigator's responsibilities in this proceeding and is governed by the disclosure safeguards contai ned in the regulations of the federal Department of Health and Human Services (45 C.F.R. §§ 160 and 1 64) under the Health Insurance Portability and Accountability Act of 1996 (Pub.L. No. 104-191 (August 21, 1996)). No use of the pr otected health information other than that which is permitted in those regulations is permitted by this order. 6. (Clerk's certification is on the next page.) Date: Judicial Officer A conservatorship proceeding under the Guar dianship—Conservatorship Law (Parts 1–4 of Division 4 of the Probate Code, section 1400 et seq.) is pending in this court for the person nam ed in the caption above as the (proposed) conservatee. Page 2 of 2 CONSERVATORSHIP OF (Name): CASE NUMBER: (PROPOSED) CONSERVATEE GC-336 [New January 1, 2009] CERTIFICATION I certify that this document is a correct co py of the original on file in my office. Clerk, by Date: , Deputy (SEAL) Date: Judicial Officer, GC-336 EX PARTE ORDER AUTHORIZING DISCLOSURE OF (PROPOSED) CONSERVATEE'S HEALTH INFORMATION TO COURT INVESTIGATOR—HIPAA (Probate—Guardianships and Conservatorships) Additional orders (specify): 8.