STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
PRIVACY OFFICE
CONFIDENTIAL
REQUEST TO ACCESS PERSONAL INFORMATION
BY PARENT, GUARDIAN OR PERSONAL REPRESENTATIVE
As a parent, guardian, or personal representative you have the right to inspect the personal records of the individual you
are authorized to represent, which the California Department of Public Health collects, creates or maintains. You also
have the right to request copies of the 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
the records mailed, you need to send us a photocopy of your California Driver’s License, Department of Motor Vehicles
Identification Card, other valid identification, and documentation verifying your authority to represent the stated individual.
You will also need to send documentation verifying your address. Note: Any attempt to falsely gain access to personal
information is subject to legal penalties. Checks should be made payable to the California Department of Public Health.
Mail, fax or email this completed form to:
Privacy Officer
California Department of Public Health
1415 L Street, Suite 500
Sacramento, CA 95814
(916) 319-9821 (fax)
privacy@cdph.ca.gov (email)
INDIVIDUAL WHOSE INFORMATION YOU ARE REQUESTING
LAST NAME:
FIRST NAME:
MIDDLE INITIAL:
ADDRESS:
CITY/STATE:
ZIP CODE:
BENEFICIARY ID NUMBER:
DATE OF BIRTH:
DATE OF DEATH (If applicable):
Death Certificate Must Be Attached
PARENT, GUARDIAN, OR PERSONAL REPRESENTATIVE INFORMATION
LAST NAME:
FIRST NAME:
MIDDLE INITIAL:
ADDRESS:
CITY/STATE:
ZIP CODE:
DAYTIME TELEPHONE NUMBER (Required): EVENING TELEPHONE NUMBER
EMAIL ADDRESS:
:
BEST HOURS TO REACH YOU
WHAT LEGAL AUTHORITY DO YOU HAVE TO REQUEST PERSONAL INFORMATION ABOUT THE INDIVIDUAL
LISTED ABOVE?
PARENT
CONSERVATOR
GUARDIAN
EXECUTOR OF WILL
MEDICAL POWER OF ATTORNEY
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.
COPY OF LEGAL DOCUMENTATION ATTACHED
TYPE (COURT ORDER/APPOINTMENT OF CONSERVATOR, GUARDIAN, ETC., MEDICAL POWER OF ATTORNEY, ATTORNEY LETTER OF REPRESENTATION,
APPOINTMENT OF GUARDIAN AD LITEM, ETC.):
DIRECTIONS
WHICH CDPH PROGRAM(S) HAS/HAVE THE PERSONAL INFORMATION OF THE INDIVIDUAL ABOVE THAT YOU WANT TO ACCESS?
AIDS Drug Assistance Program (ADAP)
OTHER (Please list CDPH program(s) which may have the personal
information)
AIDS Medi-Cal Waiver Program (MCWP)
UNKNOWN (If this box is checked, we will call you to assist in determining
Newborn Screening Program
which CDPH program(s) may have the personal information you are
requesting.)
Prenatal Screening Program
CDPH 6237 (03/18)
Page 1 of 2
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
PRIVACY OFFICE
CONFIDENTIAL
REQUEST TO ACCESS PERSONAL INFORMATION
BY PARENT, GUARDIAN OR PERSONAL REPRESENTATIVE
As a parent, guardian, or personal representative you have the right to inspect the personal records of the individual you
are authorized to represent, which the California Department of Public Health collects, creates or maintains. You also
have the right to request copies of the 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
the records mailed, you need to send us a photocopy of your California Driver’s License, Department of Motor Vehicles
Identification Card, other valid identification, and documentation verifying your authority to represent the stated individual.
You will also need to send documentation verifying your address. Note: Any attempt to falsely gain access to personal
information is subject to legal penalties. Checks should be made payable to the California Department of Public Health.
Mail, fax or email this completed form to:
Privacy Officer
California Department of Public Health
1415 L Street, Suite 500
Sacramento, CA 95814
(916) 319-9821 (fax)
privacy@cdph.ca.gov (email)
INDIVIDUAL WHOSE INFORMATION YOU ARE REQUESTING
LAST NAME:
FIRST NAME:
MIDDLE INITIAL:
ADDRESS:
CITY/STATE:
ZIP CODE:
BENEFICIARY ID NUMBER:
DATE OF BIRTH:
DATE OF DEATH (If applicable):
Death Certificate Must Be Attached
PARENT, GUARDIAN, OR PERSONAL REPRESENTATIVE INFORMATION
LAST NAME:
FIRST NAME:
MIDDLE INITIAL:
ADDRESS:
CITY/STATE:
ZIP CODE:
DAYTIME TELEPHONE NUMBER (Required): EVENING TELEPHONE NUMBER
EMAIL ADDRESS:
:
BEST HOURS TO REACH YOU
WHAT LEGAL AUTHORITY DO YOU HAVE TO REQUEST PERSONAL INFORMATION ABOUT THE INDIVIDUAL
LISTED ABOVE?
PARENT
CONSERVATOR
GUARDIAN
EXECUTOR OF WILL
MEDICAL POWER OF ATTORNEY
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.
COPY OF LEGAL DOCUMENTATION ATTACHED
TYPE (COURT ORDER/APPOINTMENT OF CONSERVATOR, GUARDIAN, ETC., MEDICAL POWER OF ATTORNEY, ATTORNEY LETTER OF REPRESENTATION,
APPOINTMENT OF GUARDIAN AD LITEM, ETC.):
DIRECTIONS
WHICH CDPH PROGRAM(S) HAS/HAVE THE PERSONAL INFORMATION OF THE INDIVIDUAL ABOVE THAT YOU WANT TO ACCESS?
AIDS Drug Assistance Program (ADAP)
OTHER (Please list CDPH program(s) which may have the personal
information)
AIDS Medi-Cal Waiver Program (MCWP)
UNKNOWN (If this box is checked, we will call you to assist in determining
Newborn Screening Program
which CDPH program(s) may have the personal information you are
requesting.)
Prenatal Screening Program
CDPH 6237 (03/18)
Page 1 of 2
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
PRIVACY OFFICE
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.
PLEASE MAIL ME A COPY OF THE REQUESTED INFORMATION.
I REQUEST THAT A PERSON OF MY CHOOSING BE ALLOWED TO INSPECT
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
REVIEW: SACRAMENTO ONLY
NAME:
RELATIONSHIP TO YOU:
TELEPHONE NUMBER:
ADDRESS:
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 REPRESENTATIVE 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 AN INDIVIDUAL
YOU LEGALLY REPRESENT 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 6237 (03/18)
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