Form DHCS6236 "Request for Access to Protected Health Information" - California

What Is Form DHCS6236?

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 DHCS6236 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 DHCS6236 "Request for Access to Protected Health Information" - California

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File Number:
File Number:
State of California
Health and Human Services Agency
Department of Health Care Services
REQUEST FOR ACCESS TO PROTECTED HEALTH INFORMATION
File Number: _________________
You have the right to inspect your protected health information in records, which Medi-Cal creates or
maintains. 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. 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
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 6236 (Rev. 01/20)
Page 1 of 5
File Number:
File Number:
State of California
Health and Human Services Agency
Department of Health Care Services
REQUEST FOR ACCESS TO PROTECTED HEALTH INFORMATION
File Number: _________________
You have the right to inspect your protected health information in records, which Medi-Cal creates or
maintains. 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. 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
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 6236 (Rev. 01/20)
Page 1 of 5
Description of the specific information
to be released/inspected
Other
From (Date)
To (Date)
Your Information
Description of the specific information
to be released/inspected
Other:
From (Date)
To (Date)
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:
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 6236 (Rev. 01/20)
Page 2 of 5
From Date
To Date
Please contact your care provider or managed care
plan if you want access to your medical records.
From Date
To Date
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:
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.
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)
______________________
____________________
DHCS 6236 (Rev. 01/20)
Page 3 of 5
I
wish
to
review
the
requested
information
in
person.
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 (Date)
Notary Public Number:
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
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
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
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 6236 (Rev. 01/20)
Page 4 of 5
This authorization for release of the above information to the above named persons or organizations will expire on:
(Date)
• I authorize the use and/or disclosure of my individually identifiable health information at the request
of the patient (myself). I understand that this authorization is voluntary.• My treatment, payment,
enrollment or eligibility for benefits will not be affected if I do not sign this authorization.• Health
Information disclosed through the authorization may be subject to disclosure and is no longer
protected if it is disclosed to anyone other than a covered entity.• I have the right to receive a copy
of this authorization.• Records and copies obtained relating to outpatient psychotherapy care shall
be returned or destroyed at the expiration date of this authorization except those obtained for
treatment and diagnosis purposes.
Member Signature:
Date:
This authorization for release of the above information to the above named persons or organizations will expire on: This authorization for release of the above
information to the above named persons or organizations will expire on:
(Date)
I understand that by signing this authorization:
Member Signature:
Date:
State of California
Health and Human Services Agency
Department of Health Care Services
This authorization for release of the above information to the above named persons or organizations
will expire on: ____________ (date).
I understand that by signing this authorization:
• I authorize the use and/or disclosure of my individually identifiable health information at the
request of the patient (myself). I understand that this authorization is voluntary.
• My treatment, payment, enrollment or eligibility for benefits will not be affected if I do not sign
this authorization.
• Health Information disclosed through the authorization may be subject to disclosure and is no
longer protected if it is disclosed to anyone other than a covered entity.
• I have the right to receive a copy of this authorization.
• Records and copies obtained relating to outpatient psychotherapy care shall be returned or
destroyed at the expiration date of this authorization except those obtained for treatment and
diagnosis purposes.
I DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION ON THIS FORM IS
TRUE AND CORRECT.
Member Signature:
Date:
DHCS 6236 (Rev. 01/20)
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