Form DHCS6241 "Request to Restrict Use and Disclosure of Protected Health Information by Parent, Guardian or Personal Representative" - California

What Is Form DHCS6241?

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 DHCS6241 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form DHCS6241 "Request to Restrict Use and Disclosure of Protected Health Information by Parent, Guardian or Personal Representative" - California

Download PDF

Fill PDF online

Rate (4.6 / 5) 39 votes
File Number:
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
File Number:
Date of Death (If applicable attached death certificate):
State of California
Health and Human Services Agency
Department of Health Care Services
REQUEST TO RESTRICT USE AND DISCLOSURE OF PROTECTED
HEALTH INFORMATION BY PARENT, GUARDIAN OR PERSONAL
REPRESENTATIVE
File Number: _________________
You have the right to request the Department of Health Care Services (DHCS) to restrict the use and
disclosure of your Medi-Cal information to carry out treatment, payment or operations. You also have
the right to request DHCS not to disclose Medi-Cal information to a family member, relative, or friend
involved with your care or payment for your health care. DHCS may not be able to agree with your
request. 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 For Whom You Are Requesting To Restrict The Use And Disclosure Of Protected
Health Information
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 6241 (Rev. 01/20)
Page 1 of 4
File Number:
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
File Number:
Date of Death (If applicable attached death certificate):
State of California
Health and Human Services Agency
Department of Health Care Services
REQUEST TO RESTRICT USE AND DISCLOSURE OF PROTECTED
HEALTH INFORMATION BY PARENT, GUARDIAN OR PERSONAL
REPRESENTATIVE
File Number: _________________
You have the right to request the Department of Health Care Services (DHCS) to restrict the use and
disclosure of your Medi-Cal information to carry out treatment, payment or operations. You also have
the right to request DHCS not to disclose Medi-Cal information to a family member, relative, or friend
involved with your care or payment for your health care. DHCS may not be able to agree with your
request. 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 For Whom You Are Requesting To Restrict The Use And Disclosure Of Protected
Health Information
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 6241 (Rev. 01/20)
Page 1 of 4
Last Name:
First Name:
Middle Initial:
Address:
City/State:
ZIP Code:
Benefits ID
Number:
Date of Birth:
Telephone Number:
E-mail Address:
Guardian
Conservator
Other:
Administrator
Guardian
Conservator
Other
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 6241 (Rev. 01/20)
Page 2 of 4
I
request
that
the
Department
of
Healthcare
Services
restrict
use
and
disclosure
of
my
protected
health
information
in
carrying
out
treatment,
payment,
or
healthcare
operations
as
follows:
I
request
that
the
Department
of
Healthcare
Services
restrict
the
use
and
disclosure
of
my
protected
health
information
to
the
following
persons:
Check All That Apply
I request that the Department of
Healthcare Services restrict use and
disclosure of myprotected health
information in carrying out treatment,
payment, or healthcare operations
asfollows:
I request that the Department of
Healthcare Services restrict the
use and disclosure of
myprotected health information
to the following persons:
State of California
Health and Human Services Agency
Department of Health Care Services
Check All That Apply
☐ I request that the Department of Healthcare Services restrict use and disclosure of my
protected health information in carrying out treatment, payment, or healthcare operations as
follows:
☐ I request that the Department of Healthcare Services restrict the use and disclosure of my
protected health information to the following persons:
DHCS 6241 (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:
Member Signature:
Date:
Type:
(Utility Bill, Phone Bill, Driver’s License, Etc.) (Utility Bill, Phone Bill,
Driver’s License, Etc.)
Type:
(CA Driver’s License, CA DMV Identification Card, Birth Certificate, Benefits
Identification 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 6241 (Rev. 01/20)
Page 4 of 4
Page of 4