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State of California—Health and Human Services Agency
California Department of Public Health

AFL 06-23
August 4, 2006

Skilled Nursing Facilities (SNFs)
Intermediate Care Facilities (ICFs)

Standard Admission Agreement - Attachment E

Attachment E was required to be a part of the Standard Admission Agreement pursuant to Section 1599.73 of the Health and Safety Code and was required by that section to conform to the Confidentiality of Medical Information Act, specifically Section 56.11 of the Civil Code. However, this form was never intended to be a substitute for compliance with the federal Health Insurance Portability and Accountability Act (HIPAA).

Several facilities have asked to alter this form so that it would also comply with HIPAA requirements. As a convenience to facilities and as authorized by Section 1599.61(b)(1) of the Health and Safety Code, facilities may add the following statements to page 2 of Attachment E before the signature of the resident:

“I understand that I am signing this authorization voluntarily and that treatment, payment or eligibility for benefits will not be affected if I do not sign this authorization.”

“I understand that I have the right to withdraw permission for the facility to release my information. If I sign this authorization to use or disclose information, I can revoke that authorization at any time. The revocation must be made in writing and will not affect information that has already been used or disclosed.”

Page 2 of Attachment E, if altered, should also include the following after the Resident's Personal Representative signature:

“Legal Authority to Act for Resident:___________________________________________________”

These additions to Attachment E should make that form compliant with both Civil Code Section 56.11 and HIPAA.
Any additional alterations to this form other than the changes specified above or to the Standard Admission Agreement must be requested in writing by the facility and approved by the Department.


Original Signed by Kathleen Billingsley, R.N.

Kathleen Billingsley, R.N.
Deputy Director

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