Form DHCS6245 "Request for an Accounting of Disclosures of Protected Health Information by Parent, Guardian or Personal Representative" - California

What Is Form DHCS6245?

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 DHCS6245 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 DHCS6245 "Request for an Accounting of Disclosures of Protected Health Information by Parent, Guardian or Personal Representative" - California

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File Number:
Date of Death: (If applicable attach death certificate)
From Date (month/day/year)
To Date (month/day/year)
REQUEST FOR AN ACCOUNTING OF DISCLOSURES OF PROTECTED HEALTH INFORMATION BY PARENT, GUARDIAN OR PERSONAL REPRESENTATIVE
File Number:
Date of Death:
From Date (month/day/year)
To Date (month/day/year)
State of California
Health and Human Services Agency
Department of Health Care Services
REQUEST FOR AN ACCOUNTING OF DISCLOSURES OF PROTECTED
HEALTH INFORMATION BY PARENT, GUARDIAN OR PERSONAL
REPRESENTATIVE
File Number: _________________
You have the right to request the Department of Health Care Services to account for the disclosures
of Medi-Cal information. You are not entitled to an accounting of disclosures to carry out treatment,
payment, or health care operations; when you have authorized the disclosure; or when the disclosure
is to the Medi-Cal beneficiary’s family, relatives, or others involved in the individuals care. You are
also not entitled to an accounting of disclosures for National Security intelligence purposes or to law
enforcement officials. Mail this completed form, along with a photocopy of your identification
and documentation of your address, to:
Privacy Officer
Department of Health Care Services
C/O Office of Legal Services
P.O. Box 997413
MS 0010
Sacramento, CA 95899-7413
(916) 445-4646
Individual 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)
I request that the department of health care services account for the disclosure of my
protected health information:
From Date (month/day/year)
To Date (month/day/year)
______________________
____________________
DHCS 6245 (Rev. 01/20)
Page 1 of 3
File Number:
Date of Death: (If applicable attach death certificate)
From Date (month/day/year)
To Date (month/day/year)
REQUEST FOR AN ACCOUNTING OF DISCLOSURES OF PROTECTED HEALTH INFORMATION BY PARENT, GUARDIAN OR PERSONAL REPRESENTATIVE
File Number:
Date of Death:
From Date (month/day/year)
To Date (month/day/year)
State of California
Health and Human Services Agency
Department of Health Care Services
REQUEST FOR AN ACCOUNTING OF DISCLOSURES OF PROTECTED
HEALTH INFORMATION BY PARENT, GUARDIAN OR PERSONAL
REPRESENTATIVE
File Number: _________________
You have the right to request the Department of Health Care Services to account for the disclosures
of Medi-Cal information. You are not entitled to an accounting of disclosures to carry out treatment,
payment, or health care operations; when you have authorized the disclosure; or when the disclosure
is to the Medi-Cal beneficiary’s family, relatives, or others involved in the individuals care. You are
also not entitled to an accounting of disclosures for National Security intelligence purposes or to law
enforcement officials. Mail this completed form, along with a photocopy of your identification
and documentation of your address, to:
Privacy Officer
Department of Health Care Services
C/O Office of Legal Services
P.O. Box 997413
MS 0010
Sacramento, CA 95899-7413
(916) 445-4646
Individual 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)
I request that the department of health care services account for the disclosure of my
protected health information:
From Date (month/day/year)
To Date (month/day/year)
______________________
____________________
DHCS 6245 (Rev. 01/20)
Page 1 of 3
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:
Last Name:
First Name:
Middle Initial:
Address:
ZIP Code:
City/State:
Benefits ID
Number:
Date of Birth:
Telephone Number:
Email Address:
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
☐ Executor of will
☐Guardian
☐ Administrator of estate
☐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 6245 (Rev. 01/20)
Page 2 of 3
Type:
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
Notary Public Number:
Type:
(Utility Bill, Phone Bill, Driver’s License, Etc.)
Type:
(CA Driver’s License, CA DMV Identification Card, Birth Card,
Managed Care Card, State Or Federal Employee ID Card)
Number:
Notarized By:
On (Date)
Notary Public Number:
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:
NOTE: ANY ATTEMPT TO FALSELY GAIN ACCESS TO PROTECTED HEALTH INFORMATION
IS SUBJECT TO LEGAL PENALTIES.
DHCS 6245 (Rev. 01/20)
Page 3 of 3
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