Form DPA487 "Request for Access to Protected Health Information" - California

What Is Form DPA487?

This is a legal form that was released by the California Department of Social 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 May 1, 2007;
  • The latest edition provided by the California Department of Social 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 DPA487 by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form DPA487 "Request for Access to Protected Health Information" - California

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STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE HEARINGS DIVISION
REQUEST FOR ACCESS TO PROTECTED HEALTH INFORMATION
State Hearing No.:_______________________
You have the right to request to inspect your protected health information in records, which State Hearings Division
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 and payment. 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 the information to:
Department of Social Services
State Hearings Division
P. O. Box 944243, MS 19-36
Sacramento, CA 94244-2430
INDIVIDUAL INFORMATION
LAST NAME
FIRST NAME
MIDDLE
INITIAL
ADDRESS
CITY/STATE
ZIP CODE
STATE HEARING NUMBER
DATE OF BIRTH
DAYTIME TELEPHONE
EVENING TELEPHONE
EMAIL ADDRESS
BEST HOURS TO REACH YOU
NUMBER
NUMBER
(Required):
(
)
(
)
WHAT TYPE OF PROTECTED HEALTH INFORMATION DO YOU WANT TO ACCESS?
METHOD TO ACCESS YOUR PROTECTED HEALTH INFORMATION
PLEASE MAIL ME A COPY OF THE REQUESTED INFORMATION.
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:
DPA 487 (5/07)
Page 1 of 2
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE HEARINGS DIVISION
REQUEST FOR ACCESS TO PROTECTED HEALTH INFORMATION
State Hearing No.:_______________________
You have the right to request to inspect your protected health information in records, which State Hearings Division
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 and payment. 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 the information to:
Department of Social Services
State Hearings Division
P. O. Box 944243, MS 19-36
Sacramento, CA 94244-2430
INDIVIDUAL INFORMATION
LAST NAME
FIRST NAME
MIDDLE
INITIAL
ADDRESS
CITY/STATE
ZIP CODE
STATE HEARING NUMBER
DATE OF BIRTH
DAYTIME TELEPHONE
EVENING TELEPHONE
EMAIL ADDRESS
BEST HOURS TO REACH YOU
NUMBER
NUMBER
(Required):
(
)
(
)
WHAT TYPE OF PROTECTED HEALTH INFORMATION DO YOU WANT TO ACCESS?
METHOD TO ACCESS YOUR PROTECTED HEALTH INFORMATION
PLEASE MAIL ME A COPY OF THE REQUESTED INFORMATION.
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:
DPA 487 (5/07)
Page 1 of 2
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE HEARINGS DIVISION
IDENTIFYING INFORMATION
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: __________________________
I DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION ON THIS FORM IS TRUE AND CORRECT.
SIGNATURE
DATE
(IF NO IDENTIFICATION IS ATTACHED YOUR SIGNATURE MUST BE NOTARIZED.)
NOTARIZED BY ___________________________________ ON ___________________(DATE).
NOTARY PUBLIC NUMBER ________________________________
UNOFFICIAL UNLESS STAMPED BY NOTARY PUBLIC.
ADDRESS VERIFICATION ATTACHED
FORM OF ADDRESS VERIFICATION _____________________________ (UTILITY BILL, PHONE BILL, DRIVER’S LICENSE,
ETC.)
NOTE: ANY ATTEMPT TO FALSELY GAIN ACCESS TO PROTECTED HEALTH INFORMATION
IS SUBJECT TO LEGAL PENALTIES.
DPA 487 (5/07)
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