Form CDPH 6234 Request for Confidential Communication - California

Form CDPH6234 or the "Request For Confidential Communication" is a form issued by the California Department of Public Health.

Download a PDF version of the Form CDPH6234 down below or find it on the 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 FOR CONFIDENTIAL COMMUNICATION
Note: If you are making this request as the personal representative of another person, (e.g., a minor, a
conservatee) please use form CDPH 6235 (Confidential Communication-Parent, Guardian or Representative)
instead of this form.
You may request the California Department of Public Health to contact you at another address or telephone
number, other than what is currently in your personal records or by a different method (such as only by mail or
only by telephone). Any attempt to falsely gain access to personal information is subject to legal penalties.
To request this, please 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
INDIVIDUAL INFORMATION
LAST NAME:
FIRST NAME:
MIDDLE INITIAL:
CURRENT ADDRESS:
CITY/STATE:
ZIP CODE:
BENEFICIARY ID NUMBER:
DATE OF BIRTH:
EVENING TELEPHONE NUMBER:
DAYTIME TELEPHONE NUMBER
EMAIL ADDRESS:
BEST HOURS TO REACH YOU:
(Required):
I REQUEST THAT THE DEPARTMENT OF PUBLIC HEALTH CONTACT ME AT A DIFFERENT ADDRESS AND/OR A DIFFERENT
TELEPHONE NUMBER THAN WHAT IS LISTED IN MY PERSONAL RECORDS BECAUSE CONTACTING ME AT MY CURRENT
ADDRESS AND/OR TELEPHONE NUMBER IS A SAFETY ISSUE FOR ME.
ALTERNATE STREET ADDRESS OR POST OFFICE BOX TO CONTACT ME:
CITY, STATE
ZIP CODE
ALTERNATE TELEPHONE NUMBER TO CONTACT ME:
I MAY ALSO REQUEST THE DEPARTMENT OF PUBLIC HEALTH TO LIMIT THE WAY IT CONTACTS ME
I REQUEST THAT THE DEPARTMENT OF PUBLIC HEALTH CONTACT ME:
(PLEASE CHECK ONE)
ONLY BY TELEPHONE
ONLY BY MAIL
ONLY BY EMAIL
DIRECTIONS
WHICH CDPH PROGRAM(S) HAS/HAVE THE PERSONAL INFORMATION ABOUT YOU THAT YOU WANT TO REQUEST FOR CONFIDENTIAL COMMUNICATION?
AIDS Drug Assistance Program (ADAP)
OTHER (Please list CDPH program(s) which may have your
AIDS Medi-Cal Waiver Program (MCWP)
personal information)
Newborn Screening Program
UNKNOWN (If this box is checked, we will call you to assist in
determining which CDPH program(s) may have your personal
Prenatal Screening Program
information you are requesting a confidential communication.)
CDPH 6234 (03/18)
Page 1 of 2
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
PRIVACY OFFICE
CONFIDENTIAL
REQUEST FOR CONFIDENTIAL COMMUNICATION
Note: If you are making this request as the personal representative of another person, (e.g., a minor, a
conservatee) please use form CDPH 6235 (Confidential Communication-Parent, Guardian or Representative)
instead of this form.
You may request the California Department of Public Health to contact you at another address or telephone
number, other than what is currently in your personal records or by a different method (such as only by mail or
only by telephone). Any attempt to falsely gain access to personal information is subject to legal penalties.
To request this, please 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
INDIVIDUAL INFORMATION
LAST NAME:
FIRST NAME:
MIDDLE INITIAL:
CURRENT ADDRESS:
CITY/STATE:
ZIP CODE:
BENEFICIARY ID NUMBER:
DATE OF BIRTH:
EVENING TELEPHONE NUMBER:
DAYTIME TELEPHONE NUMBER
EMAIL ADDRESS:
BEST HOURS TO REACH YOU:
(Required):
I REQUEST THAT THE DEPARTMENT OF PUBLIC HEALTH CONTACT ME AT A DIFFERENT ADDRESS AND/OR A DIFFERENT
TELEPHONE NUMBER THAN WHAT IS LISTED IN MY PERSONAL RECORDS BECAUSE CONTACTING ME AT MY CURRENT
ADDRESS AND/OR TELEPHONE NUMBER IS A SAFETY ISSUE FOR ME.
ALTERNATE STREET ADDRESS OR POST OFFICE BOX TO CONTACT ME:
CITY, STATE
ZIP CODE
ALTERNATE TELEPHONE NUMBER TO CONTACT ME:
I MAY ALSO REQUEST THE DEPARTMENT OF PUBLIC HEALTH TO LIMIT THE WAY IT CONTACTS ME
I REQUEST THAT THE DEPARTMENT OF PUBLIC HEALTH CONTACT ME:
(PLEASE CHECK ONE)
ONLY BY TELEPHONE
ONLY BY MAIL
ONLY BY EMAIL
DIRECTIONS
WHICH CDPH PROGRAM(S) HAS/HAVE THE PERSONAL INFORMATION ABOUT YOU THAT YOU WANT TO REQUEST FOR CONFIDENTIAL COMMUNICATION?
AIDS Drug Assistance Program (ADAP)
OTHER (Please list CDPH program(s) which may have your
AIDS Medi-Cal Waiver Program (MCWP)
personal information)
Newborn Screening Program
UNKNOWN (If this box is checked, we will call you to assist in
determining which CDPH program(s) may have your personal
Prenatal Screening Program
information you are requesting a confidential communication.)
CDPH 6234 (03/18)
Page 1 of 2
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
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, BENEFICIARY IDENTIFICATION CARD,
MANAGED CARE CARD, STATE OR FEDERAL EMPLOYEE ID CARD):
NUMBER:
(IF NO IDENTIFICATION IS ATTACHED, YOUR SIGNATURE MUST BE NOTARIZED)
(DATE)
NOTARIZED BY:
ON:
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 REQUEST FOR CONFIDENTIAL
COMMUNICATION
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 CONFIDENTIAL COMMUNICATION TO 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 45 CODE OF FEDERAL REGULATIONS, SECTION 164.522(b). 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 6234 (03/18)
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Download Form CDPH 6234 Request for Confidential Communication - California

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