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