Form DHCS6239 "Request to Amend Protected Health Information by Parent, Guardian or Personal Representative" - California

What Is Form DHCS6239?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2020;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHCS6239 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form DHCS6239 "Request to Amend Protected Health Information by Parent, Guardian or Personal Representative" - California

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File Number:
State of California
Health and Human Services Agency
Department of Health Care Services
REQUEST TO AMEND PROTECTED HEALTH INFORMATION BY
PARENT, GUARDIAN OR PERSONAL REPRESENTATIVE
File Number: _________________
You have the right to request amendments to protected health information which Medi-Cal creates or
maintains. We will act upon your request to amend within 30 days of our receipt of your request. If
your request is denied, we will let you know the reasons for the denial in writing. You have the right
to disagree with our denial of your request for amendment. You may tell us why in a written
statement of disagreement that will be added to your record. If we continue to disagree with your
requested amendment, we may place a note (rebuttal statement) in your record on why we do not
agree with your statement of disagreement. We will send you a copy of our rebuttal statement. You
also have the right, under the Information Practices Act of 1977, to request a review of the refusal to
amend a record by the head of the agency or a designee. Mail this completed form, along with a
photocopy of your identification and documentation of your address, to:
Privacy Officer
Department of Healthcare Services
C/O Office of Legal Services
P.O. Box 997413
MS 0010
Sacramento, CA 95899-7413
(916) 445-4646
Individual Whose Information You Are Amending
Last Name:
First Name:
Middle Initial:
Address:
City/State:
Zip Code:
Benefits ID Number:
Date of Birth:
Date of Death:
(If applicable attach
death certificate)
DHCS 6239 (Rev. 01/20)
Page 1 of 4
File Number:
State of California
Health and Human Services Agency
Department of Health Care Services
REQUEST TO AMEND PROTECTED HEALTH INFORMATION BY
PARENT, GUARDIAN OR PERSONAL REPRESENTATIVE
File Number: _________________
You have the right to request amendments to protected health information which Medi-Cal creates or
maintains. We will act upon your request to amend within 30 days of our receipt of your request. If
your request is denied, we will let you know the reasons for the denial in writing. You have the right
to disagree with our denial of your request for amendment. You may tell us why in a written
statement of disagreement that will be added to your record. If we continue to disagree with your
requested amendment, we may place a note (rebuttal statement) in your record on why we do not
agree with your statement of disagreement. We will send you a copy of our rebuttal statement. You
also have the right, under the Information Practices Act of 1977, to request a review of the refusal to
amend a record by the head of the agency or a designee. Mail this completed form, along with a
photocopy of your identification and documentation of your address, to:
Privacy Officer
Department of Healthcare Services
C/O Office of Legal Services
P.O. Box 997413
MS 0010
Sacramento, CA 95899-7413
(916) 445-4646
Individual Whose Information You Are Amending
Last Name:
First Name:
Middle Initial:
Address:
City/State:
Zip Code:
Benefits ID Number:
Date of Birth:
Date of Death:
(If applicable attach
death certificate)
DHCS 6239 (Rev. 01/20)
Page 1 of 4
Guardian
Conservator
Other:
Date of Birth:
Guardian
Conservator
Other:
Note: You Must Attach Legal Documentation to Verify That You Are the Parent, Guardian, Executor of a
Decedent’s Will, or Have Medical Decision-Making Authority for the Individual.
State of California
Health and Human Services Agency
Department of Health Care Services
Parent, Guardian, or Personal Representative Information
Last Name:
First Name:
Middle Initial:
Address:
City/State:
Zip Code:
Benefits ID Number:
Date of Birth:
Telephone Number:
E-mail Address:
What Legal Authority Do You Have to Request Health Information
☐Parent of a minor
☐Administrator of estate
☐Guardian
☐Executor of will
☐Conservator
☐Other: _______________________________________________________________________
Note: You Must Attach Legal Documentation to Verify That You Are the Parent, Conservator,
Guardian, Executor of a Decedent’s Will, or Have Medical Decision-Making Authority for the
Individual.
DHCS 6239 (Rev. 01/20)
Page 2 of 4
Identify the protected health
information in your Medi-Cal
record you want amended:
What you want the record to
state now: (Attach additional
paper if necessary)
State the reason you believe
the amendment needs to be
made:
Protected Health Information You Want to Amend
Identify the protected health information in
your MediCal record you want amended
What you want the record to
state now Attach additional
paper if necessary
State the reason you believe
the amendment needs to be
made
State of California
Health and Human Services Agency
Department of Health Care Services
Protected Health Information You Want to Amend
Identify the protected health information in your Medi-Cal record you want amended:
What you want the record to state now: (Attach additional paper if necessary)
State the reason you believe the amendment needs to be made:
DHCS 6239 (Rev. 01/20)
Page 3 of 4
Type:
(Utility Bill, Phone Bill, Driver’s License, Etc.)
Type
(CA Driver’s License, CA DMV Identification Card, Birth Certificate, Benefits
Identification Card, Managed Care Card, State Or Federal Employee ID Card)
Number:
Notarized By
On (date)
Notary Public Number:
Type:
Type:
(CA Driver’s License, CA DMV Identification Card, Birth (CA Driver’s License, CA DMV Identification Card, Birth
Certificate, Benefits Certificate, Benefits Identification Card, Managed Care Card, State Or Federal Employee ID Card)
Number:
Notarized By
On (date)
Notary Public Number:
Member Signature
Date
State of California
Health and Human Services Agency
Department of Health Care Services
Identifying Information:
☐Address verification attached
Type: __________________________ (Utility Bill, Phone Bill, Driver’s License, Etc.)
☐Copy of identification attached
Type: __________________________ (CA Driver’s License, CA DMV Identification Card, Birth
Certificate, Benefits Identification Card, Managed Care Card, State Or Federal Employee ID Card)
Number: ________________________
(IF NO IDENTIFICATION IS ATTACHED, YOUR SIGNATURE MUST BE NOTARIZED)
Notarized By ___________________________________ On ___________________ (Date).
Notary Public Number:________________________________
UNOFFICIAL UNLESS STAMPED BY NOTARY PUBLIC:
I DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION ON THIS FORM IS
TRUE AND CORRECT.
Member Signature:
Date:
DHCS 6239 (Rev. 01/20)
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