End of Life Option Act

Notice on Collection

Civil Code Section 1798.17 et seq. requires each state agency to provide notice to individuals completing these forms. The information is being requested by: CALIFORNIA DEPARTMENT O​F PUBLIC HEALTH, CENTER FOR HEALTH STATISTICS AND INFORMATICS, MS 5205, P.O. BOX 997377, Sacramento, CA 95899-7377. For more information, contact the End of Life Option Act (EOLA) Program at (916) 445-2890 or EOLInfo@cdph.ca.gov​. The information requested on the EOLA Reporting Forms is authorized and required by Health and Safety Code Section 443.11. Submission of the information is mandatory.

The principal purpose for these forms is:

1. To document participation in the EOLA Program and maintain compliance with the requirements of the program.
2. To facilitate creation and publication of an Annual Report.

Pursuant to California law, the information collected shall be confidential and shall be collected in a manner that protects the privacy of the patient, the patient’s family, and any medical provider or pharmacist involved with the patient. The information shall not be disclosed, discoverable, or compelled to be produced in any civil, criminal, administrative, or other proceeding.

All individuals have the right to access to records containing their personal information which are maintained by the California Department of Public Health. To obtain access to this information, please contact the EOLA Program at (916) 445-2890.