Form CDPH 6236 Request for Access to Personal Information - California

Form CDPH6236 is a California Department of Public Health form also known as the "Request For Access To Personal Information". The latest edition of the form was released in March 1, 2018 and is available for digital filing.

Download a PDF version of the Form CDPH6236 down below or find it on California Department of Public Health Forms website.

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STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
C
D
P
H
ALIFORNIA
EPARTMENT OF
UBLIC
EALTH
PRIVACY OFFICE
CONFIDENTIAL
REQUEST FOR ACCESS TO PERSONAL INFORMATION
NOTE: If you are making this request as the personal representative of another person, (e.g., a minor, a conservatee)
please use form CDPH 6237 (Access-Parent, Guardian or Representative) instead of this form.
You have the right to inspect your personal information, which the California Department of Public Health collects, creates
or maintains. You also have the right to request copies of those records. You will be charged ten (10) cents per page for
the costs of copying. You will receive a response to your request within 15 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 another type of
documentation verifying your address. Checks should be made payable to the California Department of Public Health.
Mail, fax or email this completed form to:
Privacy Officer
1415 L Street, Suite 500
Sacramento, CA 95814
(916) 319-9821 (fax)
privacy@cdph.ca.gov (email)
INDIVIDUAL INFORMATION
LAST NAME:
FIRST NAME:
MIDDLE INITIAL:
ADDRESS:
CITY/STATE:
ZIP CODE:
BENEFICIARY ID NUMBER:
DATE OF BIRTH:
DAYTIME TELEPHONE NUMBER (Required):
EVENING TELEPHONE NUMBER:
EMAIL ADDRESS:
BEST HOURS TO REACH YOU:
DIRECTIONS
WHICH CDPH PROGRAM(S) HAS/HAVE THE PERSONAL INFORMATION ABOUT YOU THAT YOU WANT TO ACCESS?
OTHER (Please list CDPH program(s) which may have your
AIDS Drug Assistance Program (ADAP)
personal information) _______________________________
AIDS Medi-Cal Waiver Program (MCWP)
UNKNOWN (If this box is checked, we will call you to assist in
Newborn Screening Program
determining which CDPH program(s) may have your personal
information you are requesting.)
Prenatal Screening Program
I AM REQUESTING COPIES OF RECORDS FOR THE FOLLOWING DATES
YOU MUST SPECIFY DATES IN ORDER TO GET RECORDS
FROM DATE (month/day/year)
TO DATE (month/day/year)
PLEASE NOTE: FULFILLING A REQUEST FOR RECORDS DATING BACK 6 YEARS AGO OR LESS IS A 30-DAY PROCESS. REQUESTS FOR RECORDS DATING
BACK PRIOR TO 6 YEARS AGO HAVE A 60-DAY TIME FRAME FOR ADDITIONAL PROCESSING.
I REQUEST THAT A PERSON OF MY CHOOSING BE ALLOWED TO INSPECT
PLEASE MAIL ME A COPY OF THE REQUESTED INFORMATION.
THE RECORDS
I WISH TO REVIEW THE REQUESTED INFORMATION IN PERSON.
.
NOTE: Any person or attorney may be named below. Records will not be sent to
IF YOU REQUEST TO REVIEW RECORDS IN PERSON, YOU WILL BE CONTACTED
photocopy services.
TO SCHEDULE AN APPOINTMENT. LOCATION AVAILABLE FOR IN PERSON
NAME: _______________________________________________________________
REVIEW: SACRAMENTO ONLY
RELATIONSHIP TO YOU: ________________________________________________
TELEPHONE NUMBER: __________________________________________________
ADDRESS: ____________________________________________________________
CDPH 6236 (03/18)
Page 1 of 2
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
C
D
P
H
ALIFORNIA
EPARTMENT OF
UBLIC
EALTH
PRIVACY OFFICE
CONFIDENTIAL
REQUEST FOR ACCESS TO PERSONAL INFORMATION
NOTE: If you are making this request as the personal representative of another person, (e.g., a minor, a conservatee)
please use form CDPH 6237 (Access-Parent, Guardian or Representative) instead of this form.
You have the right to inspect your personal information, which the California Department of Public Health collects, creates
or maintains. You also have the right to request copies of those records. You will be charged ten (10) cents per page for
the costs of copying. You will receive a response to your request within 15 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 another type of
documentation verifying your address. Checks should be made payable to the California Department of Public Health.
Mail, fax or email this completed form to:
Privacy Officer
1415 L Street, Suite 500
Sacramento, CA 95814
(916) 319-9821 (fax)
privacy@cdph.ca.gov (email)
INDIVIDUAL INFORMATION
LAST NAME:
FIRST NAME:
MIDDLE INITIAL:
ADDRESS:
CITY/STATE:
ZIP CODE:
BENEFICIARY ID NUMBER:
DATE OF BIRTH:
DAYTIME TELEPHONE NUMBER (Required):
EVENING TELEPHONE NUMBER:
EMAIL ADDRESS:
BEST HOURS TO REACH YOU:
DIRECTIONS
WHICH CDPH PROGRAM(S) HAS/HAVE THE PERSONAL INFORMATION ABOUT YOU THAT YOU WANT TO ACCESS?
OTHER (Please list CDPH program(s) which may have your
AIDS Drug Assistance Program (ADAP)
personal information) _______________________________
AIDS Medi-Cal Waiver Program (MCWP)
UNKNOWN (If this box is checked, we will call you to assist in
Newborn Screening Program
determining which CDPH program(s) may have your personal
information you are requesting.)
Prenatal Screening Program
I AM REQUESTING COPIES OF RECORDS FOR THE FOLLOWING DATES
YOU MUST SPECIFY DATES IN ORDER TO GET RECORDS
FROM DATE (month/day/year)
TO DATE (month/day/year)
PLEASE NOTE: FULFILLING A REQUEST FOR RECORDS DATING BACK 6 YEARS AGO OR LESS IS A 30-DAY PROCESS. REQUESTS FOR RECORDS DATING
BACK PRIOR TO 6 YEARS AGO HAVE A 60-DAY TIME FRAME FOR ADDITIONAL PROCESSING.
I REQUEST THAT A PERSON OF MY CHOOSING BE ALLOWED TO INSPECT
PLEASE MAIL ME A COPY OF THE REQUESTED INFORMATION.
THE RECORDS
I WISH TO REVIEW THE REQUESTED INFORMATION IN PERSON.
.
NOTE: Any person or attorney may be named below. Records will not be sent to
IF YOU REQUEST TO REVIEW RECORDS IN PERSON, YOU WILL BE CONTACTED
photocopy services.
TO SCHEDULE AN APPOINTMENT. LOCATION AVAILABLE FOR IN PERSON
NAME: _______________________________________________________________
REVIEW: SACRAMENTO ONLY
RELATIONSHIP TO YOU: ________________________________________________
TELEPHONE NUMBER: __________________________________________________
ADDRESS: ____________________________________________________________
CDPH 6236 (03/18)
Page 1 of 2
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
C
D
P
H
ALIFORNIA
EPARTMENT OF
UBLIC
EALTH
PRIVACY OFFICE
REQUIRED IDENTIFYING INFORMATION
To process your request, you must provide verification of address and identification.
COPY OF ADDRESS VERIFICATION ATTACHED
TYPE (UTILITY BILL, PHONE BILL, DRIVER’S LICENSE, ETC.): _______________________________________________________________________
COPY OF IDENTIFICATION ATTACHED
TYPE (DRIVER’S LICENSE, 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.
REQUESTING INDIVIDUAL’S SIGNATURE: ________________________________________________________________ DATE: _________________________
DEPARTMENT EMPLOYEE PROCESSING/MAINTAINING THIS ACCESS REQUEST
THIS SECTION TO BE COMPLETED BY DEPARTMENT STAFF
(Name and Title)
(Organization within Department)
(Telephone Number)
(Mail Stop Number)
PRIVACY STATEMENT (CA CIVIL CODE SECTION 1798.17)
THE INFORMATION COLLECTED ON THIS FORM IS USED TO PROCESS YOUR REQUEST FOR ACCESS TO PERSONAL INFORMATION ABOUT YOU
THAT IS MAINTAINED BY THE CALIFORNIA DEPARTMENT OF PUBLIC HEALTH (DEPARTMENT). THE INFORMATION WE COLLECT FROM YOU ON
THIS FORM WILL BE KEPT CONFIDENTIAL AND ON FILE AT THE DEPARTMENT, AS REQUIRED BY LAW. ALL INFORMATION REQUESTED ON THE
FORM IS MANDATORY PURSUANT TO CALIFORNIA CIVIL CODE SECTION 1798.32. NOT SUPPLYING THE INFORMATION REQUESTED WILL RESULT
IN THE DENIAL OF YOUR REQUEST. ANY INFORMATION PROVIDED MAY BE DISCLOSED TO THE CALIFORNIA STATE AUDITOR, THE CALIFORNIA
OFFICE OF HEALTH INFORMATION INTEGRITY, THE CALIFORNIA OFFICE OF INFORMATION SECURITY AND PRIVACY PROTECTION, THE U.S.
DEPARTMENT OF HEALTH AND HUMAN SERVICES OR TO OTHER STATE AND FEDERAL AGENCIES AS REQUIRED BY LAW.
YOU HAVE THE RIGHT TO REVIEW THE RECORDS WE KEEP ABOUT YOU DURING NORMAL BUSINESS HOURS. THE CALIFORNIA DEPARTMENT OF
PUBLIC HEALTH PRIVACY OFFICER WILL, UPON REQUEST, INFORM YOU REGARDING THE LOCATION OF YOUR RECORDS AND THE CATEGORIES
OF ANY PERSONS WHO USE THE INFORMATION IN THOSE RECORDS. FOR MORE INFORMATION, CONTACT THE CALIFORNIA DEPARTMENT OF
PUBLIC HEALTH, PRIVACY OFFICE, USING THE FOLLOWING CONTACT INFORMATION: CALIFORNIA DEPARTMENT OF PUBLIC HEALTH, OFFICE OF
LEGAL SERVICES, PRIVACY OFFICE, 1415 L STREET, SUITE 500, SACRAMENTO, CALIFORNIA 95814 OR BY PHONE 1-877-421-9634.
CDPH 6236 (03/18)
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Download Form CDPH 6236 Request for Access to Personal Information - California

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