Form DHCS6247 "Authorization for Release of Protected Health Information to Third Parties" - California

What Is Form DHCS6247?

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 DHCS6247 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form DHCS6247 "Authorization for Release of Protected Health Information to Third Parties" - California

Download PDF

Fill PDF online

Rate (4.7 / 5) 44 votes
File Number:
File Number:
State of California
Health and Human Services Agency
Department of Health Care Services
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH
INFORMATION TO THIRD PARTIES
File Number: _________________
By completing this form you are authorizing the California Department of Health Care Services to
release your protected health information identified herein to the persons or entities identified herein.
You also have the right to request copies of those 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’s license, Department of Motor Vehicles
Identification Card, or other valid identification. You will also need to send documentation verifying
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 address below:
Department of Health Care Services
DHCS/MEDI-CAL FI
P. O. Box 526018
Sacramento, CA 95852-6018
(916) 636-1980
Your Information
Last Name:
First Name:
Middle Initial:
Address:
City/State:
Zip Code:
Benefits ID Number:
Date of Birth:
Telephone Number:
E-mail Address:
DHCS 6247 (Rev. 01/20)
Page 1 of 7
File Number:
File Number:
State of California
Health and Human Services Agency
Department of Health Care Services
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH
INFORMATION TO THIRD PARTIES
File Number: _________________
By completing this form you are authorizing the California Department of Health Care Services to
release your protected health information identified herein to the persons or entities identified herein.
You also have the right to request copies of those 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’s license, Department of Motor Vehicles
Identification Card, or other valid identification. You will also need to send documentation verifying
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 address below:
Department of Health Care Services
DHCS/MEDI-CAL FI
P. O. Box 526018
Sacramento, CA 95852-6018
(916) 636-1980
Your Information
Last Name:
First Name:
Middle Initial:
Address:
City/State:
Zip Code:
Benefits ID Number:
Date of Birth:
Telephone Number:
E-mail Address:
DHCS 6247 (Rev. 01/20)
Page 1 of 7
Name:
Position or Role:
Address:
City/State/Zip:
Telephone Number:
Fax Number:
Name:
Position or Role:
Address:
City/State/Zip:
Telephone Number:
Fax Number:
Description of the Specific Information
to be Released/Inspected:
From
To
Name:
Position or Role:
Address:
City/State/Zip:
Telephone Number:
Fax Number:
Name:
Position or Role:
Address:
City/State/Zip:
Telephone Number:
Fax Number:
Description of the Specific
Information to be
Released/Inspected:
Other:
Information from the categories above will be authorized for the following period of time:
To (date)
From (date)
State of California
Health and Human Services Agency
Department of Health Care Services
Person/Organization Providing the
Person/Organization to Receive the
Information
Information
Name: _________________________________
Name: _________________________________
Position or Role: _________________________
Position or Role: _________________________
Address: _______________________________
Address: _______________________________
City/State/ZIP: __________________________
City/State/ZIP: __________________________
Telephone Number: ______________________
Telephone Number: ______________________
Fax Number: ___________________________
Fax Number: ___________________________
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).
DHCS 6247 (Rev. 01/20)
Page 2 of 7
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):
I Am Requesting Copies of Records for the Following Dates of Service:
From Date
To Date
Description of the Purpose and Limitations for the Release or Inspection of the
Information (Indicate How Information Will Be Used):
State of California
Health and Human Services Agency
Department of Health Care Services
Check Each Type of Protected Information You Want to Access:
☐ Claim Detail Reports, which contain claims
Managed Care Records:
☐ Enrollment Records
paid by Medi-Cal for services received.
☐ 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.
I Am Requesting Copies of Records for the Following Dates of Service:
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.
DHCS 6247 (Rev. 01/20)
Page 3 of 7
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:
Middle Initial:
First Name:
Address:
City/State:
ZIP Code:
Benefits ID
Number:
Date of Birth:
Telephone
Number:
E-mail 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 6247 (Rev. 01/20)
Page 4 of 7
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
or
attorney
may
be
named
below.
Records
will
not
be
sent
to
photocopy
services.
Name:
Address:
Telephone Number:
Relationship to you:
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
personor
attorney
may
be
named
below.
Records
will
not
be
sent
to
photocopy
services.
Name:
Telephone Number:
Address:
Relationship to you:
State of California
Health and Human Services Agency
Department of Health Care Services
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 6247 (Rev. 01/20)
Page 5 of 7
Page of 7