Revised Medical Information Authorization Form

The Department of Pesticide Regulation (DPR) revised the Medical Information Authorization form (DPR-ENF-133 [English] and DPR-ENF-133X [Spanish] Rev. 7/13) to include the patient’s date of birth. Most, if not all, hospitals and medical offices have electronic systems that use name and date of birth to retrieve patient information. The addition of this personal identifier will make it easier for hospitals to locate a patient’s records quickly and more accurately when county staff requests them as part of an illness investigation. In addition to the birthdate, we modified the form to improve clarity and ease of reading.

The Enforcement Branch is in the process of printing new forms that should be available in 6-8 weeks. Please submit a DPR-197 Forms Requisition request to the Enforcement Branch to order these forms. DPR recommends you discard any outdated Medical Information Authorization forms (dated 2/04 or older). If you need a Medical Information Authorization form before you receive your order, please print and use the enclosed form. If you use a printed copy, please be sure the person signing the form gets a copy. The form is also available on the DPR website at English or Spanish.

If you have any questions regarding the changes to the form, please contact Nino Yanga of the Worker Health and Safety Branch at (916) 445-6387 or syanga@cdpr.ca.gov.

Sincerely,