Form DHCS6237 "Request to Access Protected Health Information by Parent, Guardian or Personal Representative" - California

What Is Form DHCS6237?

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 DHCS6237 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 DHCS6237 "Request to Access 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 ACCESS PROTECTED HEALTH INFORMATION BY
PARENT, GUARDIAN OR PERSONAL REPRESENTATIVE
File Number: _________________
As a parent, guardian, or personal representative you have the right to inspect the Medi-Cal records
of the individual you are authorized to represent. You also have the right to request copies of the
records. You will receive a response to your request within 30 days after we receive your request. If
you want copies of your records mailed, you need to send us a photocopy of your California driver
license or other listed identification and documentation verifying your authority to represent the stated
individual. You will also need to send documentation verifying your address, such as a utility bill
displaying your address. Please check the box on page three of this document if you would also
like a copy of the requested records sent to you. Mail this completed form to:
Department of Health Care Services
DHCS/MEDI-CAL FI
P.O. Box 526018
Sacramento, CA 95852-6018
(916) 636-1980
Directions
Please read the following before completing this form. If any of the circumstances below
applies to you, you may not need to fill out this form.
You have a personal injury case and Medi-Cal has paid for services related to the injury and you want
information about these services and/or payments.
Or
You are requesting access to records on behalf of a deceased Medi-Cal beneficiary in order to repay
Medi-Cal for services received by the deceased beneficiary. You may have received an Estate
Recovery Questionnaire in the mail.
Or
You are involved in a worker’s compensation case in which Medi-Cal has paid for services for the
injury you received while on the job.
Please call (916) 650-0490 for further information about these circumstances.
If none of these circumstances apply, please complete the form.
DHCS 6237 (Rev. 01/20)
Page 1 of 6
File Number:
State of California
Health and Human Services Agency
Department of Health Care Services
REQUEST TO ACCESS PROTECTED HEALTH INFORMATION BY
PARENT, GUARDIAN OR PERSONAL REPRESENTATIVE
File Number: _________________
As a parent, guardian, or personal representative you have the right to inspect the Medi-Cal records
of the individual you are authorized to represent. You also have the right to request copies of the
records. You will receive a response to your request within 30 days after we receive your request. If
you want copies of your records mailed, you need to send us a photocopy of your California driver
license or other listed identification and documentation verifying your authority to represent the stated
individual. You will also need to send documentation verifying your address, such as a utility bill
displaying your address. Please check the box on page three of this document if you would also
like a copy of the requested records sent to you. Mail this completed form to:
Department of Health Care Services
DHCS/MEDI-CAL FI
P.O. Box 526018
Sacramento, CA 95852-6018
(916) 636-1980
Directions
Please read the following before completing this form. If any of the circumstances below
applies to you, you may not need to fill out this form.
You have a personal injury case and Medi-Cal has paid for services related to the injury and you want
information about these services and/or payments.
Or
You are requesting access to records on behalf of a deceased Medi-Cal beneficiary in order to repay
Medi-Cal for services received by the deceased beneficiary. You may have received an Estate
Recovery Questionnaire in the mail.
Or
You are involved in a worker’s compensation case in which Medi-Cal has paid for services for the
injury you received while on the job.
Please call (916) 650-0490 for further information about these circumstances.
If none of these circumstances apply, please complete the form.
DHCS 6237 (Rev. 01/20)
Page 1 of 6
Guardian
Conservator
Other:
State of California
Health and Human Services Agency
Department of Health Care Services
Your Information
Last Name:
First Name:
Middle Initial:
Address:
City/State:
Zip Code:
Benefits ID Number:
Date of Birth:
Telephone Number:
E-mail Address:
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 6237 (Rev. 01/20)
Page 2 of 6
Description of the Specific Information to be Released/Inspected
HIV or AIDS
Alcohol/Drug Information
Mental Health/Behavioral
Health Genetic Testing
Information from the categories above will be authorized for the following period of time:
To (Date)
From (date)
Claim Detail Reports, which contain
claims paid by Medi-Cal for services
received.
Enrollment Records
Disenrollment Records
Capitation Paid to Health Plan
MERS Fair Hearing Documentation
Treatment/Service Authorization Request Screens.
Printouts contain patient names, which providers have
requested services, which services were requested, the
decision about the service(s), including a simple
description of the decision, and whether the provider has
billed for these services.
Genetically Handicapped Persons Program (GHPP) and/or
California Children’s Services (CCS) Records.
Case Management Records, which
contain case manager notes.
State of California
Health and Human Services Agency
Department of Health Care Services
Description of the Specific Information to be Released/Inspected
Check each type of confidential information you authorize to be released/inspected:
☐ HIV or AIDS
☐ Alcohol/Drug Information
☐ Mental Health/Behavioral
☐ Health Genetic Testing
Other:
Information from the categories above will be authorized for the following period of time:
from_____________ (date) to_____________ (date).
Check Each Type of Protected Information You Want to Access:
☐ Claim Detail Reports, which contain claims
Managed Care Records:
paid by Medi-Cal for services received.
☐ Enrollment Records
☐ Disenrollment Records
☐ Capitation Paid to Health Plan
☐ MERS Fair Hearing Documentation
☐ Treatment/Service Authorization Request
Denti-Cal Records:
Screens. Printouts contain patient names, which
Call (800) 322-6384
providers have requested services, which
services were requested, the decision about the
☐ Genetically Handicapped Persons
service(s), including a simple description of the
decision, and whether the provider has billed for
Program (GHPP) and/or California Children’s
these services.
Services (CCS) Records.
☐ Case Management Records, which contain
Please contact your care provider or managed
care plan if you want access to your medical
case manager notes.
records.
DHCS 6237 (Rev. 01/20)
Page 3 of 6
From Date
To Date
Description of the Purpose and Limitations for the Release or Inspection of the
Information (Indicate How Information Will Be Used)
I
wish
to
review
the
requested
information
in
person.
I
request
that
a
person
of
my
choosing
be
allowed
to
inspect
my
records
note
any
person.
Note:
Any
person
or
attorney
may
be
named
below.
Records
will
not
Name:
Telephone Number
Address
Relationship to you
State of California
Health and Human Services Agency
Department of Health Care Services
I am requesting copies of records for the following dates of service:
You must specify dates of service in order to get records.
From Date (month/day/year)
To Date (month/day/year)
______________________
____________________
Description of the Purpose and Limitations for the Release or Inspection of the Information
(Indicate How Information Will Be Used)
The information will not be used for any purpose other than its intended use.
Please note: A request for records of services provided up to six years ago is a 30-day process. All
other requests have an approximate 60-day time frame for additional processing.
☐ Please mail me a copy of the requested information.
☐ I wish to review the requested information in person.
If you request to review records in person, you will be contacted to schedule an appointment.
Location available for in person review: Sacramento Only
☐ I Request That a Person of My Choosing be Allowed to Inspect My Records. Note: Any person
or attorney may be named below. Records will not be sent to photocopy services.
Name: ___________________________________
Telephone number: _________________________
Address: _________________________________
Relationship to you: _________________________
DHCS 6237 (Rev. 01/20)
Page 4 of 6
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:
State of California
Health and Human Services Agency
Department of Health Care Services
Requestor's 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:
DHCS 6237 (Rev. 01/20)
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