Form CDPH 6238 Request to Amend Personal Information - California

Form CDPH6238 is a California Department of Public Health form also known as the "Request To Amend 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 CDPH6238 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
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
PRIVACY OFFICE
CONFIDENTIAL
REQUEST TO AMEND 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 6239 (Amend-Parent, Guardian or Representative) instead of this form.
You have the right to request amendments to your personal information which the California Department of Public Health
creates or maintains. We will act upon your request to amend within 30 days of our receipt of your request. If your
request is denied, we will let you know the reason(s) for the denial in writing. You have the right to disagree with our
denial of your request for amendment. You may tell us why in a written statement of disagreement which will be added to
your record. If we continue to disagree with your requested amendment, we may place a note (rebuttal statement) in your
record on why we do not agree with your statement of disagreement. We will send you a copy of our rebuttal statement.
You also have the right, under the Information Practices Act of 1977, to request a review of the refusal to amend a record
by the head of the agency or a designee. Mail, fax or email this completed form, with a photocopy of your identification
and documentation of your address, 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 AMEND?
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 amending.)
Prenatal Screening Program
PERSONAL INFORMATION YOU WANT TO AMEND
IDENTIFY THE PERSONAL INFORMATION IN YOUR RECORDS YOU WANT AMENDED:
CDPH 6238 (03/18)
Page 1 of 2
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
PRIVACY OFFICE
CONFIDENTIAL
REQUEST TO AMEND 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 6239 (Amend-Parent, Guardian or Representative) instead of this form.
You have the right to request amendments to your personal information which the California Department of Public Health
creates or maintains. We will act upon your request to amend within 30 days of our receipt of your request. If your
request is denied, we will let you know the reason(s) for the denial in writing. You have the right to disagree with our
denial of your request for amendment. You may tell us why in a written statement of disagreement which will be added to
your record. If we continue to disagree with your requested amendment, we may place a note (rebuttal statement) in your
record on why we do not agree with your statement of disagreement. We will send you a copy of our rebuttal statement.
You also have the right, under the Information Practices Act of 1977, to request a review of the refusal to amend a record
by the head of the agency or a designee. Mail, fax or email this completed form, with a photocopy of your identification
and documentation of your address, 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 AMEND?
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 amending.)
Prenatal Screening Program
PERSONAL INFORMATION YOU WANT TO AMEND
IDENTIFY THE PERSONAL INFORMATION IN YOUR RECORDS YOU WANT AMENDED:
CDPH 6238 (03/18)
Page 1 of 2
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
PRIVACY OFFICE
WHAT YOU WANT THE RECORD TO STATE NOW: (ATTACH ADDITIONAL PAPER IF NECESSARY)
STATE THE REASON YOU BELIEVE THE AMENDMENT NEEDS TO BE MADE:
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 AMENDMENT 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 AMENDMENT OF 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 SECTIONS 1798.35, 1798.36, AND 1798.37 AND HEALTH & SAFETY CODE SECTION 123111. 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 6238 (03/18)
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Download Form CDPH 6238 Request to Amend Personal Information - California

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